| 100000290 |
Riverwood Health Care |
030009216 |
A |
28-Nov-12 |
FIQ911 |
12444 |
Admission Of Patients - 72515 The licensee shall: (b) Accept and retain only those patients for whom it can provide adequate care. Patient Rights - 72527 (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. An unannounced visit was made on 11/12/09 to investigate Complaint #CA00208053 and CA00205143, an Entity Reported Event regarding patient abuse.As a result of the investigation, it was determined the facility failed to: 1. Protect Patient 1 from abuse by Patient 2, who had a history of violence towards other residents and failed to ensure that the facility accepted and retained only patients for whom they could provide adequate care.Patient 1 and Patient 2 were roommates. On 10/14/09 at approximately 3:45 a.m. Patient 2 punched Patient 1 in the face causing Patient 1 to fall to the ground sustaining injuries and a decline in Patient 1's condition.Patient 1 was an 83 year old male, admitted from home, to the facility on 8/3/09 with diagnoses which included dementia and blindness. An MDS (Minimum Data Set, an assessment tool), dated 8/14/09, described the patient as having short term and long term memory problems and being moderately impaired for daily decision making. The MDS described the patient as having highly impaired vision. Patient 1 was described in the MDS as being independent for most activities of daily living, could get out of bed and walk independently and required staff set up for hygiene. The MDS described the patient as being continent of bowel and bladder functions and listed his only negative behavior as occasionally resisting care offered by staff. Patient 1 was documented to be 6 feet 2 inches tall and weighed 141 pounds. Patient 2 weighed 120pounds more than Patient 1 and was known to intimidate other patients. Patient 1 was blind and confused and needed to rely upon staff for his protection.Review of the clinical record for Patient 1 included the following documented information: Nurse's Note dated 10/14/09 at 5 a.m. documented, "Patient experiences confusion. Patient was assaulted by roommate. Punched socked in face, knocked to floor, causing a laceration with swelling and bleeding. Punch caused patient to fall to floor. Patient complained of pain to face and left hip and leg...New order given for x-ray left hip...transferred to (different room)." An Interdisciplinary Team (IDT) note dated 10/14/09 documented, "On 10/14/09 at 3:45 a.m. patient was found laying on the floor, it was observed that his roommate (Patient 2) was walking away from this resident. Patient was bleeding from a laceration on top upper lip. Patient stated 'I was socked square in the face.' This knocked him to the floor he stated 'I must have been kicked or something' in the left hip and leg. Patient complained of pain in left hip and leg. Swelling noted in left hip area...unaware of the events due to his cognitive status." A Nurse's Note dated 10/15/09 at 9 a.m. documented, "Patient stand up with help, cannot walk. Noted signs of pain. Patient said 'my leg hurt'...Patient sat up in his chair with two people helping...Patient cannot stand without help and cannot walk." Nurse's Note dated 10/16/09 at 3 p.m. documented, "Stayed in bed all day." Review of ADL Flow Records for 10/1 through 10/14/09 documented the patient was independent, requiring no staff help or oversight, in the following activities of daily living (ADL): bed mobility; eating; transfers; toilet use and walking in his room and in the hall. ADL Records for 10/15 through 10/19/09 documented the patient required extensive staff assistance for bed mobility, transfers and toilet use. The ADL records documented the patient no longer walked in his room or in the hall after 10/15/09. An IDT noted dated 10/19/09 at 4:00 p.m. documented: "Patient is moving some better today...still having difficulty walking." The Physician's Progress note dated 10/19/09 documented, "resident is now a feeder, no longer walking in hallways."The presence of bruising on the left lower leg was noted, "x-ray negative"In an interview with Certified Nurse Assistant (CNA) 2 on 11/13/09 at 9 a.m. she stated Patient 1 "wasn't himself after the injury." She stated he was delicate and fragile, saying 'ow' when moved.She stated it took 2 people to transfer Patient 1 after the incident with Patient 2. CNA 2 stated "he wasn't the same. Before he got hit he walked, was continent, dressed himself and put on his shoes. The hit must have rattled him real bad." A Nurse's Note dated 10/20/09 at 4:40 a.m. documented "patient was unconscious....no respirations, no pulse...CPR was done. At 4:52 p.m. the notes documented "Patient was taken to (a general acute care hospital)." Review of Patient 1's clinical record from the general acute care hospital (GACH) where he was transferred on 10/20/09 documented Patient 1 arrived in the emergency room at 5:10 a.m. and was pronounced dead at 5:11 a.m. Patient 2 was a 65 year old male, admitted to the facility on 7/21/09 with diagnoses which included paranoid schizophrenia and dementia. An MDS, dated 8/3/09, described the patient as having short term and long term memory problems and being moderately impaired for daily decision making. Patient 2 was described in the MDS as being independent for most activities of daily living, could get out of bed and walk independently and required staff assistance for dressing and personal hygiene. The MDS documented that Patient 2 was 6 feet 2 inches tall and his weight was 262 pounds.Review of the facility's clinical record for Patient 2 included: A history and physical exam from an acute psychiatric hospital (APH), where the patient was confined immediately prior to being transferred to the skilled nursing facility (SNF) was reviewed. The document listed the admission date to the APH as 5/27/09. Under History of Present Illness: "...transferred from (name of skilled nursing facility where he resided previously, SNF 2). The patient has history of schizophrenia...Reportedly has been evaluated because of aggressive behaviors, throwing things, choking another patient." The report described Patient 2 as being 6 feet, 1 inch tall. Under Assessment the report described Patient 2 as having "1. Psychosis. 2. Agitation." This report included a fax transmission date of 7/18/09 prior to Patient 2's transfer to the facility.A Psychiatric Evaluation from the APH dated 6/16/09 documented Patient 2 had been transferred from SNF 2 to the APH as "Due to physical aggressiveness in the form of running patients over with his wheelchair, punching, threatening behaviors." Physician's Orders on admission to the SNF dated 7/21/09, included: "Monitor every shift...for episodes of aggressive behavior manifested by hitting others." And "Monitor every shift ...for episodes of aggressive behavior manifested by choking others." The Medication Administration Record for September and October 2009 included directions to monitor every shift for aggressive behavior manifested by hitting others, and choking others. Marks were made by a nurse on every shift during these 2 months indicating there was no evidence of hitting or choking by Patient 2. A care plan titled Behavior Problem Identification, dated 7/23/09 which included "History of verbal abuse, striking out, kicking delusions, choking others. Treats staff very well but is sometimes abusive to residents-threatens verbally." Under the column for approaches for these behaviors, there were no items regarding protection of other residents. A second care plan titled Behavior Problem Identification was dated 7/24/09 listed problems as "Striking out, kicking, Other: Treats the staff very well, but is sometimes abusive to residents-Threatens patients verbally." Under the column for approaches for these behaviors, there were no items regarding protection of other residents. A Nurse's Note, dated 10/2/09 at 11 a.m. which included: "Patient stop the roommate to turn on TV he say 'do not turn on'." A Nurse's Note, dated 10/4/09 at 11 p.m. which included: "Patient 2 was verbally abusive to roommate (Patient 1), because he lay down in his bed. Verbalized, 'if you don't get off there I'm going kick your ass'." A physician's progress note dated 10/06/09 from the psychiatrist documented, "Concern - combative"..."agitated, intrusive, demanding"... "Increase Risperdal (a medication to control behavior) to 1 milligram three times daily."A physician's order dated 10/06/09 requested a psychiatric evaluation for increased aggressiveness. The Physician's Progress Note dated 10/06/09 documented, "Combative"...agitated, intrusive, demanding." The MD increased his Risperdal to 1 mg three times daily.A Nurse's Note, dated 10/8/09, titled Weekly Summary, which included: "Patient has 2 episodes of behavior aggressive with other resident." A Nurse's Note, dated 10/14/09 at 5:25 a.m. which included: "Patient had an altercation (with) Roommate. He assaulted roommate by punching in face, knocking him to the floor. Possibly kicking patient also."A Physician's Order, dated 10/14/09 at 12:30 p.m. indicated "send patient out to (name of APH). Beat up roommate." In an interview with Director Of Nursing (DON) on 11/13/09 at 9:30 a.m. she stated "I knew he (Patient 2) had a history. The doctor at (name of APH) said it wasn't going to be a problem, they'd take him back if need be." She also stated "He was at (name of previous skilled nursing facility), we called them, and he had been known to have behaviors." She stated the facility protected other residents by "Not placing psychiatric patients with him or noisy, irritating patients." When asked why Patient 2 was not immediately transferred to the APH on 10/14/09 after his aggressive and abusive behavior, she stated "They didn't have room for him." In an interview with Licensed Nurse (LN) 1 on 11/12/09 at 7:20 p.m. she stated she was not aware Patient 2 had a violent history. She stated Patient 2 "sometimes messed with (name of Patient 1), argued." In an interview with CNA 1 on 11/12/09 at 6:50 p.m. she stated Patient 2 was "a big guy, and strong." She stated she was not aware he had injured other residents. In an interview with CNA 4 on 11/12/09 at 7:05 p.m. she stated in October Patient 1 was confused and had lain on Patient 2's bed. Then Patient 2 "got violent, had a bad temper and threatened (name of Patient 1)."In an interview with CNA 5 on 11/12/09 at 7:25 p.m. she stated "(Named Patient 2) a nice guy, I didn't know he was violent." She stated Patient 1 was really confused and would lie down in Patient 2's bed. She stated "He can't see well. I guide him and hold his hand."In an interview with CNA 3 on 11/13/09 at 10:45 a.m. he stated he frequently cared for Patient 2. He stated he was not aware Patient 2 had a history of violence. The above direct caregivers were not made aware of his history of aggressive behaviors and need to provide protections for other patients in contact with Patient 2.As a result of the failure to protect Patient 1, he sustained a direct blow to the face, was knocked to the ground and kicked by Patient 2. He had resulting hip pain and a significant decline in his ability to ambulate, increased need for assistance with ADL activities and decline in his quality of life. Patient 1 died six days after the attack by Patient 2.The facility also failed to adequately inform direct care staff of Patient 2's violent history and failed to protect Patient 1 from injury despite two documented threats from Patient 2.The facility failed to protect Patient 1 from abuse by Patient 2, who had a history of violence towards other residents, and failed to ensure that the facility accepted and retained only patients for whom they could provide adequate care.These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. |
| 030000076 |
Rosewood Post Acute Rehabilitation |
030009612 |
B |
20-Dec-12 |
OCQY11 |
5097 |
F323 483.25 Free of Accident Hazards/Supervision/Devices (h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. An unannounced visit was made on 10/30/09 to initiate investigation of Complaint #CA00206425. As a result of the investigation, it was determined that the facility failed to ensure Resident A received adequate assistance from facility staff when being transferred from the wheelchair to the bed. The failure resulted in Resident A sustaining a broken tibia (lower leg bone) on 10/27/09 when Certified Nursing Assistant (CNA1) attempted to transfer her from the wheelchair to the bed without assistance from other staff or a lifting device. A Fall Investigation summary dated 10/30/09 documented CNA1 and Resident A lost their balance during the transfer. CNA1 lowered Resident A to the floor and with help from CNA2, assisted Resident A to stand and get into the bed. Resident A was re-admitted to the facility on 5/29/09 with diagnoses that included degenerative joint disease and muscle weakness. A Minimum Data Set (MDS, an assessment tool used to plan patient care) dated 8/17/09 indicated Resident A was moderately cognitively impaired. Resident A was unable to walk and had full loss of range of motion and voluntary movement for both legs. Resident A was totally dependent for transfers, needing two or more persons to physically assist her during transfer from the wheelchair to the bed. Resident A's weight was listed as 203 pounds. A fall risk assessment dated 8/17/09 documented a score of 14 for Resident A. The form's key indicated a score of 10 or greater represented high fall risk. Review of Resident A's "Fall Risk" care plan revealed no intervention related to the 8/17/09 MDS assessment identifying Resident A as totally dependent for transfers requiring at least two persons to physically assist her during transfer. Resident A was transferred to an acute care hospital at about 9 p.m. on 10/27/09. The hospital record was reviewed. An x-ray report dated 10/27/09 documented Resident A sustained a fracture of her left proximal (nearer the knee than the foot) tibia. An "E.D. Patient Assessment and Care Notes" dated10/27/09 at 10 p.m., documented Resident A's complaint of left leg pain as a constant ache, rated a "7" on a pain scale (Zero represented the patient was pain free; 10 represented the worst pain ever). The form documented 1 mg intravenous Dilaudid (brand name for hydromorphone, a narcotic pain reliever) was administered to Resident A for pain relief. A discharge summary dated 10/28/09 documented Resident A was not a candidate for surgery and her left leg fracture was treated with a rigid immobilizer. Resident A was discharged from the acute care hospital the next day. In an interview with the Director of Nursing (DON) on 10/30/09 at 9:30a.m., he stated that on 10/27/09 CNA1 was pivoting Resident A when Resident A slipped and her leg went backwards. The CNA called for help and CNA2 helped get the resident to bed. The DON stated both CNAs had been disciplined because the facility had a "NO lift" policy in place. The "No lift" policy meant that mechanical lifts were to be used with transfer of patients who needed assistance. The facility "Safety Instructions: Lifting and Patient Handling" procedure was reviewed and stipulated (in part) the following: "The following rules are minimum standards with which we expect all employees to comply. . . Remember this is a NO-LIFT facility. Safe techniques are essential to handling a patient. To do it correctly, you should follow these safety instructions... Get help if you have to move a patient. Use the correct device, such as the [brand names of patient lift devices] assigned to the patient to do the job safely and easily." The fall on 10/27/09 was avoidable given Resident A's clinical information: 1. Admitting diagnoses of degenerative joint disease and muscle weakness; 2. MDS data documenting Resident A had full loss of range of motion in her lower extremities and was totally dependent on two or more persons to transfer; 3. A fall risk assessment placing Resident A as "high risk" for falls; 4. Resident A weighed over 200 pounds; 5. Resident A's transfer needs were not addressed in the care plan. In addition, the facility had a "No lift" policy and safety rules for lifting and patient handing in place. These rules were not followed by CNA1 who performed the transfer by herself without help from another staff member or a mechanical device. Resident A's fall on 10/27/09 resulted in an admission to the acute care hospital, pain, and a broken leg. The potential for more serious injury existed. Therefore, the Department determined the facility failed to ensure that: Resident A received adequate assistance from facility staff when being transferred from the wheelchair to the bed. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000011 |
Rock Creek Care Center |
030009884 |
B |
09-May-13 |
I2YK11 |
2821 |
72527 Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. An unannounced visit was made to the facility on 5/28/2010 to initiate the investigation of Complaint(s) #CA00228340 (An Entity Reported Incident) and #CA00229482. As a result of the investigation, it was determined that the facility failed to: Ensure the patient was free from mental abuse. Patient A's medical record was reviewed. Patient A was admitted to the facility on 04/19/2010. He was a 75 year old male with admitting diagnoses including recent hip fracture, advanced dementia, and heart disease. His admission MDS (Minimum Data Set; an assessment tool) dated 4/29/2010 documented Patient A had short and long term memory deficit and moderately impaired decision making ability. He required extensive assistance with activities of daily living and was non-ambulatory.The Physical Restraint Assessment dated 4/29/2010 indicated Patient A was "unable to follow directions" and had "poor safety awareness."In a hand written and signed statement, LVN (Licensed Vocational Nurse) 2 wrote that he and another staff member assisted Patient A back to bed after he had gotten out of bed on the evening of 5/8/2010 ( the facility report indicated the time to be approximately 6:30 to 7 p.m.). The statement further indicated, "LVN 1 came into the room and yelled "oh my God, what are you (Patient A) doing? You can't keep doing this. Let's get him on the bed and I'll get him a Norco (narcotic pain medication) so he'll go to sleep. This can't be going on all night." His statement further detailed LVN 1 was being "short" with Patient A.In a hand written signed statement, Patient B wrote, "LVN1 walked in and in more of a loud angry voice started to ask [Patient A] why he was up and began lecturing him like she has many times...I do know that [Patient A] was terribly confused and upset by the whole ordeal... [Patient A] doesn't even know what he's doing that's wrong...[Patient A] was near tears."In a letter to the Department, the Director of Nursing wrote. "The investigation concerning the alleged verbal abuse of [Patient A] has concluded that verbal abuse did occur." Therefore, the Department determined that the facility failed to ensure Patient A was free from mental abuse.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100001639 |
RCCA - WAWONA |
030009886 |
B |
16-May-13 |
GX0L11 |
5272 |
Health and Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation was written as a result of an unannounced visit on 3/2/10 to investigate entity reported incident number CA00189885. The Department determined the facility failed to: 1. Report an allegation made by Client 1 on 5/25/09 that another client "hurt me" within 24 hours to the Department. 2. Implement facility abuse policy and procedures regarding investigation of allegations of abuse and documentation of a resolution within five working days. These failures resulted in: 1. Delay of the facility reporting the allegation to the Department for greater than 24 hours. 2. Failure to thoroughly investigate the allegation, thus failure to protect Client 1 from possible further abuse or injury. Review of "A & I (Accident & Injury) Management Notification Form," dated 5/25/09 at 7 a.m., revealed facility staff discovered Client 1 had "red bumps on elbows." The Notification Form indicated the facility's Quality of Life Manager (QLM) and registered nurse were notified by telephone. Review of "Investigation of Management Notification Form," dated 5/25/09, revealed three staff interviews were conducted regarding Client 1's observed injury. All interviews were dated "5/26." The first interview indicated the QLM was "called on 5/25 and told about bruises on [Client 1's] arms." The interview notes indicated the QLM was told by Client 1, via staff sign language interpreter, the bruises "were from [Client 2]." The second interview was conducted with a Direct Care Staff (DCS) member. The DCS indicated Client 1 signed that the bruises "were from [Client 2] ... [Client 2] hurt me." There was no further information (e.g., interview with Client 2). The "Special Incident Report (SIR)", dated 5/27/09, indicated "... it is possible another resident touched her arm and [startled] her, resulting in her pulling away and causing a bruise." There was no documented evidence an investigation was done that provided evidence to support the conclusion in the SIR. Review of "Intake Information" revealed the facility reported Client 1's bruises to the Department on 5/27/09 at 10:59 a.m. (greater than 46 hours after the allegation was made by Client 1 to facility staff).Review of the SIR, dated 6/8/09, revealed that on 6/7/09 at approximately 1 a.m. Client 2 "entered the bathroom which [Client 1] was [using] ... An investigation has been initiated ... Specific preventive actions taken or planned ...: Emergency [Human Rights Committee - HRC] will be convened." This incident occurred 13 days after Client 1 alleged that Client 2 "hurt me."Review of the "Emergency Human Rights Committee Meeting" notes, dated 6/11/09, revealed the purpose of the meeting was to "discuss the relationship between clients [2] and [1]. The clients have previously been romantically involved, but since their relationship ended, [Client 1] has expressed that she is not interested in having relations with [Client 2]. [Client 2] has made several advances towards [Client 1] ... The advances appear to be unwanted ... HRC Team recommendations: [facility] management feels that it would be safer for [Client 1] and [Client 2] if [Client 2] moved to an all-male [facility] house nearby." The facility's policy and procedure titled Abuse/Neglect/Mistreatment, dated 12/4/03, indicated, in part, "... All instances of abuse/neglect/mistreatment will be responded to timely by using the guidelines in this policy ... [Page 2 Investigate] Upon [facility] Management notification of possible abuse/neglect/mistreatment an investigation is initiated with a written resolution within 5 working days ..." On 3/2/10 at 8:40 a.m., the QLM was requested to provide information regarding the delay in reporting the allegation of abuse to the Department. The QLM did not provide any further information or documentation. On 3/2/10 at 2:30 p.m., Area Director (AD) 1 was requested to provide any information or documentation regarding the above incidents. AD 1 did not provide any further information or documentation. On 7/19/10 at 11:45 a.m. and 7/26/10 at 9:10 a.m., AD 2 was requested to provide information and/or documentation regarding delay of reporting, investigation, and actions taken to protect Client 1. On 10/29/10 at 1:30 p.m., AD 1 was again requested to provide information regarding reporting delay, investigation, and actions taken related to the above incidents. No further information or documentation was provided related to delay in reporting, investigation, or action taken to protect Client 1.The Department determined the facility failed to: 1. Report an allegation made by Client 1 on 5/25/09 that another client "hurt me" within 24 hours to the Department. 2. Implement facility abuse policy and procedures regarding investigation of allegations of abuse and documentation of a resolution within five working days. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 100001681 |
RCCA - DUTRA PLACE |
030010011 |
B |
18-Jul-13 |
RT0411 |
5176 |
76876.Nursing Services--Administration of Medication (d)Persons administering medications shall confirm each client identity prior to the administration. The following citation was written as a result of an unannounced visit to the facility on 7/14/11 to investigate entity reported incident number CA00274271 and complaint number's CA00276881 and CA00274753. The Department determined the facility failed to identify Client A before administering medications. This failure resulted in Client A receiving Client B's medications and consequently sending him to the hospital with a significant decrease in blood pressure (BP) and respiratory arrest. Client A was a 59 year old admitted to the facility on 9/5/00. He had diagnoses including cerebral palsy and spasticity. Client A's medications included Valium (for muscle spasms) and hydrochlorothiazide (to decrease lung fluid buildup). Side effects of Valium and hydrochlorothiazide included low blood pressure and respiratory arrest. Client B was a 30 year old admitted to the facility on 6/30/10. He had diagnoses including seizure disorder and high blood pressure. Client B's medications included Depakote (for seizure disorder), Neurontin (for seizure disorder), Lotensin (for high blood pressure), and Cogentin (for side effects of certain medications). Side effects of these four medications included respiratory failure, irregular heart rhythms, and low blood pressure. Qualified Mental Retardation Professional (QMRP) Notes, dated 6/23/11, were reviewed. A note at 7:30 a.m. indicated Client A had received his medications as well as Client B's medications. After a call was made to 911, Client A was transported to the General Acute Care Hospital (GACH). A note at 9 a.m. indicated Client A had been discharged from the GACH and had no new orders. The Area Director (AD) and Registered Nurse (RN) assessed Client A and decided to provide him with individual coverage. His vital signs, including his blood pressure, were to be taken every hour or more as needed. A note at 1 p.m. indicated Client A's blood pressure had dropped, 911 was called, and he was transported back to the GACH. Nurse's Notes, dated 6/23/11, were reviewed. Documentation (no time recorded) indicated Client A was sent to the ER in the morning because he was given the wrong medications. He returned from the GACH with no treatments. Client A's normal BP was 110/68. At 1:30 p.m., Client A had a BP of 95/64 that dropped to 70/43. Client A became unresponsive. He was transported by ambulance back to the GACH. Emergency Department physician documentation, dated 6/23/11, was reviewed. Client A was given Narcan to reverse the effects of the medications. Dopamine was given to increase his blood pressure. Client A was placed on a ventilator to assist with his breathing. Client A's Emergency Department diagnoses included accidental drug overdose and respiratory arrest. Client A remained hospitalized from 6/23/11 until 7/5/11. The facility's Investigative Report regarding the medication administration error on 6/23/11 was reviewed. The report contained interviews with two Direct Care Staff (DCS). The interview on 6/23/11 with DCS 1 indicated she had begun passing medications at 6:15 a.m. She successfully gave Client A his medications first, then gave two other clients their medications. The interview indicated she usually gave Client B his medications last because he leaves the facility last. "She stated that she completed [Client B's] medication set up by punching all of his AM medications into a medication cup and placing applesauce into the cup. She then locked up the medication cards and carried the filled medication cup to the refrigerator with the bottle of apple sauce. She then put the applesauce in the refrigerator and when she closed the refrigerator door, [Client A] was standing in the kitchen facing her. She stated that she 'just gave him the medications' and realized her error as he was swallowing the medications..." The facility interview with DCS 2 was conducted on 6/27/11. According to the interview, Client A was sitting at the table and Client B was on the couch facing the TV. After preparing Client B's medications, DCS 1 went to the refrigerator to get applesauce to put in the cup with Client B's medications. "She then turned around and gave the medicine to [Client A] at the table, instead of [Client B]." An interview was conducted with the Area Director (AD) on 7/14/11 at 7:55 a.m. The AD stated Client A had already received his medications. She stated Client A was "right there" with DCS 1 and she gave him the medications. The AD acknowledged Client A was sent to the GACH and then released home to sleep it off. Client A had a staff member assigned to monitor him. When he didn't look right, his blood pressure was checked. Client A's blood pressure had dropped drastically. He was sent back to the GACH. The AD stated, "We gave him the wrong meds." The Department determined the facility failed to identify Client A before administering medications. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000090 |
Roseville Care Center |
030010172 |
B |
02-Oct-13 |
J73S11 |
4848 |
72515 Admission of Patients The licensee shall: (b) Accept and retain only those patients for whom it can provide adequate care.On August 12, 2013 an Informal Conference was conducted as part of the Complainant Appeal process provided in the California Health & Safety Code Section 1420 (b) (c). The Department findings of Complaint #CA00292023 were reviewed and documents re-evaluated. Based on family statements and document review it was determined that the facility failed to: Only accept a patient for whom it could provide adequate care. Patient 1 was admitted to the facility from the general acute care hospital (GACH) on 11/25/2011. His underlying diagnosis was severe dysphagia (trouble swallowing) and end stage respiratory failure with recent aspiration pneumonia. There were physician orders for comfort care only and he would not be resuscitated.On admission to the facility 11/25/2011 at 5:30 pm, Patient 1 had an intravenous access line in place. Family Member A and B documented in a written statement the presence of the access line at the time of admission Prior to transfer to the facility the medical orders included intravenous (IV) morphine (a narcotic used for pain and respiratory distress) via a continuous infusion device for symptom management after discharge to the skilled nursing facility. GACH records documented the arrangements for IV comfort care to be provided by the facility. The family of Patient 1 had elected to admit him to the facility because they were told that this facility was the only skilled nursing facility in the area with the ability to administer intravenous fluids and medications. The initial physician orders were for medications for symptom management to be given intravenously. After admission, the order for morphine was changed from intravenously to subcutaneously (SQ - into the tissue below the skin). Patient 1's family was not informed of the change until the nursing staff came in to set up the new system. Family stated that had they known he would not get the medication as they were expecting, they would have had Patient 1 taken home for end of life care. They were concerned and anxious since they had finally seen Patient 1 relieved of his cough and respiratory distress with the medication given IV with additional medication readily provided if his coughing became worse.The facility DON (Director of Nursing) indicated during an interview on 12/12/11 at 3 pm, that there was a facility policy they could not give morphine IV but there was no written policy provided that documented this limitation. An undated facility policy, Intravenous Therapy - General Policies Procedures and Protocols, was provided and indicated that pain medications could be administered IV.Family member A and B both stated that the staff setting up the SQ system seemed very unfamiliar with the process. Family Member A felt Patient 1 was being used as a "guinea pig." At least one member of the family remained at the bedside at all times during his stay.Patient 1's primary distress was related to respiratory issues and a dry cough as opposed to obvious pain. His cough persisted from admission without significant sustained relief.In a written statement, Family Member B documented that on 11/26/2011 at approximately 12:30 am, Family Member B asked Nurse 1 to contact the doctor to see if there was something more that could be done to relieve Patient 1's cough, described as "a loud, persistent cough that would not stop." The nurse indicated to the family member that the physician in charge "did not answer calls at night and only a voice mail message could be left. If it were an emergency, they would have to send the patient to the emergency room and that she had left a message for the physician to call back."The Nurse's Notes dated 11/26/2011 documented the message for the physician was left at 12:30 am. Despite documentation of continued coughing there was no documented evidence of any attempt to contact another physician or the Medical Director to ensure Patient 1's comfort. The family was left with the impression that there was no medical support for Patient 1 to ensure his comfort. In the GACH, his symptoms had been relieved with the continuous IV infusion with as needed additional doses of the morphine. Patient 1 died that same night at 3:40 am. During an interview later with Nurse 1 on 1/5/12 at 1:30 pm, she stated that she had thought of calling the medical director for the facility but had not done so. In the interim, Patient 1 continued with respiratory distress and a cough despite the medical order for "comfort care." Therefore, the facility failed to:Only accept a patient for whom it could provide adequate care. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000076 |
Rosewood Post Acute Rehabilitation |
030010206 |
B |
23-Oct-13 |
OZPD11 |
4457 |
F323 - Free of Accident Hazards/supervision/devices 483.25(h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. An unannounced visit was made to the facility on 11/2/10 to initiate investigation of Complaint #CA00247395. As a result of the investigation, it was determined the facility failed to ensure the resident received adequate supervision to prevent Resident A from eloping from the facility on 10/23/10 at about 7 p.m. This failure resulted in a risk of harm for Resident A when he was outside of the facility without staff knowledge. Review of Resident A's clinical record showed the facility admitted Resident A on 9/26/10 with diagnoses that included altered mental status, difficulty in walking and weakness. A History and Physical, dated 9/26/10, indicated "The patient is generally confused and weak." Two weekly Nurses' Progress Notes, one dated 10/15/10 through 10/21/10, and one dated 10/22/10 through 10/28/10 were reviewed. Both documents noted Resident A had problems with long and short term memory, impaired decision making ability, and although he knew who he was, he was confused about where he was and what time it was.A care plan titled "Falls & Injury," dated 9/26/10, listed "altered mental status" as a problem for Resident A. The nursing intervention for this problem was "Be alert regarding resident's whereabouts." In a California Department of Public Health (CDPH) complaint intake, a complainant witness stated at approximately 7 p.m. on 10/23/10, she witnessed an elderly man in a wheelchair beginning to cross the street.In a phone interview with the California Highway Patrol (CHP) dispatcher on 11/4/10 at 9:40 a.m., he stated the CHP received a "911" call from a citizen on 10/23/10 which was forwarded to the Sacramento County Sheriff Department (SCSD) at 7:21 p.m.Review of a SCSD report dated 10/23/10 at 7:21 p.m., indicated a call was made to SCSD from CHP reporting a 90 year old in a wheelchair, dressed in a hospital gown, at an intersection near the facility. The report further detailed calling the facility at 7:34 p.m. and 7:36 p.m. to see if the missing resident belonged there. At 7:40 p.m., after verifying Resident A was not in his bedroom, a facility employee came out to the street to retrieve him. The SCSD report witness statement read as follows: "Saw subj. [Resident A] attempting to cross [street names] in . . . wheelchair/stopped [Resident A] . . . " A Nurses' Note dated 10/24/10 at 3:55 a.m. indicated (referring to the previous evening) "Resident continued to propel self to main hallway then later was noted to have gone outside [unable to read] briefly. Was returned to facility, received by RN [Registered Nurse] supervisor [NS]." In an interview with CNA 1 on 11/4/10 at 3:15 p.m., she stated she was present in the facility on 10/23/10. She stated she did not see Resident A leave the facility and was unaware Resident A was missing until the resident was brought back into the facility by the NS. CNA 1 was unable to recall what time she last saw Resident A on 10/23/10, but she thought it was between 6:30 and 7 p.m. because she remembered she wanted to give care to him around that time, but the resident refused care and kept insisting he wanted to go outside and smoke.In a handwritten statement by RN 1, dated 11/2/10 at 5:15 p.m., he wrote that he saw Resident A wheeling down the main hallway. He then saw Resident A about two hours later when he was brought back into the facility by the NS. The facility admitted Resident A with a diagnosis of altered mental status. Facility nurses documented Resident A was cognitively impaired and was not oriented to time or place. These deficits were listed in a Care Plan that instructed facility staff to "Be Alert regarding resident's whereabouts." The SCSD report showed that on 10/23/10, Resident A was outside the facility for a minimum of 20 minutes. The witness statement showed that Resident A was outside for up to 40 minutes and was "Beginning to cross the street." These events had the potential of causing harm to Resident A. Therefore, the Department determined the facility failed to provide adequate supervision to prevent accidents.This violation had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 030000076 |
Rosewood Post Acute Rehabilitation |
030010256 |
AA |
13-Nov-13 |
07SF11 |
15839 |
72311 - Nursing Services - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (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.72311 - Nursing Services - 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: (F) Any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient.72311 - Nursing Services - General (b) All attempts to notify licensed healthcare practitioners acting within the scope of his or her professional licensure shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending licensed healthcare practitioner acting within the scope of his or her professional licensure or his or her designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g). 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. 72547 - Content of Health Record (a) A facility shall maintain for each patient a health record which shall include: (5) Nurses' notes which shall be signed and dated. Nurses' notes shall include: (D) Justification for the results of the administration of all PRN medications and the withholding of scheduled medications. Unannounced visits were made to the facility on 12/13/12 and 12/31/12 to investigate an Entity Reported Incident, #CA00103216. As a result of the investigation, the Department determined the facility failed to: 1) Ensure an individualized written patient care plan was developed and implemented for Patient A, 2) Notify Patient A's physician of an administration of a medication which was life threatening and presented a risk to the patient, 3) Ensure written policies and procedures were implemented,4) Maintain clinical records in accordance with professional standards. These failures resulted in Patient A sustaining an acute subdural hematoma (a collection of blood between the brain and the membrane lining the skull) subsequent to an over dose of Warfarin (an anti-coagulant or "blood thinner"). The bleeding resulted in Patient A's death. Review of Patient A's clinical record indicated she was admitted to the facility on 12/15/06 and her diagnoses included femur fracture requiring surgery, chronic renal insufficiency (decrease in kidney function), high blood pressure, and dementia. According to her record Patient A had lived at a board and care facility where she had a fall that required surgery and was admitted to the facility for rehabilitative therapy.Patient A's Admission Nursing Assessment dated 12/15/06, described her as alert, friendly and cooperative, as being disoriented to place and person and unable to answer questions appropriately.Review of Patient A's record indicated the following physician's orders were recorded: 1. Warfarin (an anticoagulant or "blood thinner") 5 milligrams (mg) to be given one time on 12/17/12 . 2. A laboratory blood test called PT/INR (Prothrombin Time/International Normalized Ratio) was to be checked weekly on Monday (the first Monday after the order was written was 12/18/06) to monitor the effectiveness of the Warfarin.PT is a blood test that measure how long it takes blood to clot and is used when patients receive a blood thinner, such as Warfarin, to measure the effectiveness of the drug. INR-International Normalized Ratio measures the time it takes for blood to clot and standardizes the PT by comparing it to an average. The normal INR reference range is 0.90 to 1.10; and the reference range to prevent post-surgical DVT (Deep Vein Thrombosis, a blood clot in a deep vein, usually in the legs) is 2.0 to 3.0. The manufacturer's labeling information for Warfarin includes a "black box" warning (the strongest adverse effect information required by the Food and Drug Administration) indicating the medication has the potential to cause major or fatal bleeding. Risk factors include high intensity of anticoagulation (INR greater than 4.0), high blood pressure and renal insufficiency. 3. Nursing staff was to call Patient A's physician for further Warfarin orders on 12/18/06 after the facility received the PT/INR results. On 12/18/06 the physician ordered Warfarin 5 mg daily to prevent DVT and PT/INR on Thursday 12/21/06. A laboratory report dated 12/18/06 indicated Patient A's INR was 2.09 (reference range for DVT prevention 2.0-3.0), and therefore within the acceptable range to prevent DVT.A laboratory report dated 12/21/06 indicated Patient A's INR was 2.92 and therefore within the acceptable range to prevent DVT. Review of Patient A's record revealed no documentation that the physician was notified of the laboratory results. A laboratory report dated 12/26/06 indicated Patient A's INR was 5.48 HP (HP next to the lab value indicated the result was high at panic level) (reference range for DVT prevention 2.0-3.0). There was no documented evidence that Patient A's physician was notified of the high (panic level) results. Review of a policy titled, "Lab Work, Ordering of," dated 3/95, indicated "Purpose: To ensure all laboratory tests are performed as ordered, on a timely basis and that all test results are reported to the physician when received by the facility." The policy also indicated that "5. A licensed nurse may take phone reports of lab results and record it on a preliminary telephone report form... 6. A licensed nurse will phone the lab results to the physician and make notation on the report of the date, time, and who the results were given to, one report will be filed in the chart until replaced by a printed report. A licensed progress note will be made of lab results, physician notification and any new orders. 7. A licensed nurse will review the reports and initiate appropriate measures when indicated, including infection control procedures."During an interview with the DON (Director of Nursing), on 12/13/12 at 11:45 a.m., she confirmed there was no documented evidence that the physician was notified of Patient A's PT/INR results on 12/21/06 and 12/26/06, per the facility's policy. She further confirmed she would expect some type of documentation to be in the chart.Review of a fax from the laboratory dated 1/4/07 at 11:16 a.m., with Patient A's PT/INR results dated 12/26/06, indicated the PT/INR results were called and "accurately" read back by Licensed Nurse (LN) 1. The facility supplied an example of a pre-printed care plan titled, "Risk for bleeding due to use of anticoagulant therapy," dated January 1995. Review of Patient A's record revealed no evidence that this care plan or any other care plan related to Patient A's anticoagulation therapy was developed for Patient A.During an interview with the DON, on 12/13/12 at 11:45 a.m., she confirmed there was no care plan regarding Patient A's anticoagulation therapy. Review of Patient A's Daily Medicare Note, dated 1/1/07 AM Shift (no exact time), indicated Patient A had a "large bruise on the left hip. Bleeding from surgery staples."Resident A's Nurse's Notes dated 1/1/07 at 9:40 a.m. indicated Patient A was noted at approximately 9:15 a.m. with a decreased level of consciousness (LOC). Patient A was described as "non-verbal" at the time with "some moaning," "movement responsive to touch." Patient A's physician was notified. Patient A required transfer to the Emergency Room (ER) of a general acute care hospital (GACH) for evaluation, admission and treatment.Review of Patient A's Medication Sheet, for December 2006, indicated that Warfarin 5 mg was given once daily from 12/18-12/24/06. The Medication Administration Record (MAR) indicated that from 12/25-12/30/06 the licensed nurses initials were circled. There was no entry for 12/31/06. During an interview with the DON, on 12/13/12 at 11:10 a.m., she confirmed initials with a circle around them indicated the patient did not take or refused the medication. Review of the facility's policy titled, "Refused Medication or Drugs not Given," undated, indicated "1. Licensed Nurse initials and circles the medication record and documents the reason for omission on the back of the medication record. 2.The Licensed Nurse shall promptly notify the physician of the 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 resident. 3. Documentation shall include all attempts to notify the physician, method of communication and name of person acknowledging contact." During an interview with the DON, on12/13/12 at 11:45 a.m., she confirmed there was no documentation, on the back of the medication record, of the reason why the Warfarin was charted as not given to Patient A by LNs from 12/25-12/30/06. The DON also confirmed there was no documented evidence the LNs notified the physician of the inability to obtain or administer Warfarin, per the facility's policy.Review of a facility document titled "Investigation Report of Incident," with the "Date of incident: 1/1/07" indicated Patient A was "found with change in LOC." The "Investigation Report of Incident," indicated the facility reviewed Patient A's chart and laboratory reports and noted that Patient A's PT/INR were at "panic level" and that "this was not acted upon by the nurse on duty who then gave Warfarin in error." Review of a facility document titled, "Investigation of [Patient A]," dated 1/4/07, indicated that Patient A's labs were reviewed and "it was noted that the labs on 12/26/06 were unanswered by the in house nursing staff. The lab was a critical PT/INR out of range" The facility's investigation report indicated the facility's Administrator called the lab company to see if the lab called or faxed the report to the facility. The lab indicated they spoke to LN 1 on 12/26/06 who read back the PT/INR report. LN 1 was assigned to Patient A on 12/26/06. The investigation report indicated that LN 1 gave the Warfarin on 12/26/06 and that LN 1 indicated he did not look to see if a lab had come back. Other nurses were questioned and they indicated they gave the Warfarin on the days following the date of the lab (12/26/06-12/30/06). The facility's investigation report indicated Patient A's MAR had circles around the Warfarin doses for 12/25-12/30/06. The facility investigative report indicated when the facility questioned some of the nurses about the circled initials, they said they gave the Warfarin as ordered (12/25-12/30/06) and they did not know about the circles around the initials and did not know of an order to hold (not give) the Warfarin.Review of a facility's document titled, "Incident/Accident Report," with a "Date of incident/accident" as 1/1/07. The document indicated Patient A was given Warfarin without verification of the lab results (which was a critical lab value) that was called by the laboratory to LN 1. Review of Patient A's GACH Emergency Room Report, with a "Date of Treatment: 1/1/07" indicated Patient A's INR was greater than 13 [reference range for DVT prevention 2.0-3.0]."Review of Patient A's laboratory results from 1/1/07 showed her RBC (Red Blood Cell Count) was extremely low at 1.61 (reference range 4.00-5.40 M/ul), indicating significant anemia. RBCs carry oxygen from the lungs to the rest of the body. If the RBC count is low (anemia) the body may not be getting the oxygen it needs. Patient A's HGB (Hemoglobin) was 5.2 C ("C" indicates critical) (reference range 12.0-16.0 g/dl). Hemoglobin measures the blood's ability to carry oxygen throughout the body. Patient A's HCT (Hematocrit) was significantly decreased at 14.9 L ("L" indicates low) (reference range 36.0-47.0%). Hematocrit shows the amount of blood volume that is made up of red blood cells.Review of Patient A's GACH History and Physical (H & P) dated 1/1/07 indicated (in part) in the section "Physical Examination" under "General" that Patient A "was unresponsive even to painful stimuli." In the "Neurologic" section Patient A was described as "unresponsive and appeared to be posturing [abnormal body positions commonly seen with brain injury or swelling]." According to the H & P a CT scan [a computerized scan of body parts] of the head was done and revealed an "Acute subdural hematoma." The H & P indicated Patient A had an "Acute subdural hematoma secondary to supratherapeutic (above the therapeutic level) INR" and "profound anemia (when the number of healthy red blood cells in the body is too low)."A subdural hematoma is a collection of blood between the brain and the skull. As blood accumulates it compresses the brain. The pressure on the brain causes the symptoms of the subdural hematoma. If pressure inside the skull rises to very high level, a subdural hematoma can lead to unconsciousness and death.According to the H & P dated 1/1/07, Patient A was not a likely surgical candidate secondary to her multiple medical problems. The GACH discharge summary documented "Admitted with acute subdural hematoma. Evidence of uncal herniation (a result of pressure from bleeding or any expanding lesion, portions of the brain push against the section of the brain that controls blood pressure, heart rate and respiration. If not corrected, the increased pressure will result in death.) on CT. Patient continued to decline and expired."Patient A expired on 1/1/07. No autopsy was performed.Patient A had laboratory tests that indicated the amount of Warfarin she was receiving was too high. Facility nursing staff did not respond to the abnormal lab reports but continued to administer the anticoagulant Warfarin, which exposed Patient A to the potential of abnormal bleeding. Facility staff did not develop a care plan indicating the goals of the Warfarin therapy and the interventions necessary to safely administer the drug. Facility staff did not notify the physician of Patient A's abnormal laboratory results. Facility staff documented Patient A's Warfarin was not given 12/25-12/30/06, but the facility's investigation of the incident indicated the LNs involved gave the Warfarin 12/25-12/30/06 and did not know why the MAR showed documentation that the medication was not given. There was no entry for Warfarin on 12/30/06 so it was not clear if the medication was given or not. The laboratory reports at the GACH indicated a "supratherapeutic" PT/INR. On 1/1/07, Patient A died due to increased brain pressure from bleeding into the skull The Department determined the facility failed to: 1) Ensure an individualized written patient care plan was developed and implemented for Patient A, 2) Notify Patient A's physician of an abnormally high PT/INR which was life threatening and presented a risk to the patient, 3) Ensure written policies and procedures were implemented,4) Maintain clinical records in accordance with professional standards. These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom and were a direct proximate cause of death of the patient or resident. |
| 030000004 |
Roseville Point Health & Wellness Center |
030013349 |
B |
14-Jul-17 |
P39H11 |
10241 |
F204 Title 42 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.
The following citation is written as a result of an investigation of complaints #CA00505151, CA00506045, and CA00506097 which alleged that on 10/6/16 Resident 1 was transferred to a facility unqualified to meet her care needs.
The Department determined the facility failed to ensure Resident 1 was transferred to a safe location when she was discharged to a Room and Board facility not equipped to meet the high medical needs of Resident 1. As a result of this failure, Resident 1 was at risk of injury or neglect.
These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility residents.
Resident 1 had been a resident of the facility for several years. Her diagnoses included long term use of insulin (injected medication for the treatment of a chronic blood sugar disorder). Her 8/11/16 Minimum Data Set, (MDS, an assessment tool), indicated she had mild cognitive problems, was totally dependent on staff to transfer between her bed and chair, could not walk, could not self-propel her own wheelchair, could not dress herself, use the toilet, or perform her own personal hygiene. The MDS also indicated Resident 1 was frequently incontinent of urine.
The clinical record for Resident 1 contained the following information:
On 5/30/16 the Medical Doctor (MD) ordered daily injections of the insulin "Toujeo".
An 8/7/16 "Resident Plan of Care for Activities of Daily Living" indicated Resident 1 needed assistance with "Bed mobility, walking, locomotion, dressing, transfer, eating, toilet use, personal hygiene, and bathing." The plan of care indicated Resident 1 needed extensive assistance due to her obesity, depression, and weakness. The plan of care directed staff to use adaptive equipment which included a wheel chair and a sling lift to transfer Resident 1 from her bed to chair.
On 9/02/16 the MD ordered injections of the insulin Humalog to be administered three times a day, with meals.
The Activities of Daily Living (ADL) Log for 10/1/16-10/5/16 indicated Resident 1 required the following care:
For bed mobility, the staff documented Resident 1 was totally dependent on 2 staff people to turn her in bed on most of the shifts during that period.
For transferring between the bed and wheelchair, the staff documented Resident 1 was totally dependent on 2 staff members to assist her with transferring on most of the shifts during that period.
For walking, the staff documented Resident 1 did not walk.
A 10/3/16 Discharge Meeting note indicated a meeting was held with the Director of Nursing (DON), the Social Service Director (SSD), a therapy representative and a dietary representative. The Ombudsman (OMB) attended the meeting, and the Representative Party (RP) for Resident 1 attended the meeting by telephone. The note indicated the purpose of the meeting was concern for Resident 1's unhappiness at being at that facility and to address the request to be closer to her family in another town. The note indicated a Room and Board (R&B) facility that agreed to provide care services was located closer to Resident 1's family. (Room and Board facilities usually provide residents with a room, a bed, and prepared meals for a set fee.) Arrangements were made for the delivery of the durable medical equipment Resident 1 would need at the R&B.
A 10/4/16 "Notice of Proposed Transfer/Discharge" indicated Resident 1 was being transferred to a "Room and Board". The rationale given for the transfer was "The discharge is necessary for your welfare and your needs cannot be met in the facility."
In an interview with the Administrator (ADM) on 10/6/16 at 2:55 p.m., he reported Resident 1 had been discharged that day to a R&B facility whose operator (RBO) agreed to meet Resident 1's care needs. The ADM reported he believed the discharge was appropriate because Resident 1 was unhappy at the facility, the R&B operator was aware of Resident 1's care needs, and appropriate equipment had been ordered for Resident 1's use at the R&B. The ADM reported since Resident 1 was being discharged to a private home, the R&B operator could agree to take on resident's as a private agreement. The ADM reported the R&B operator had an opportunity to meet Resident 1 and review her records before agreeing to take her. The ADM reported it was the responsibility of the RBO to ensure he had the ability to provide Resident 1's care needs. The ADM reported a Placement Agency (PA, an independent organization that helps people with care needs find appropriate placement) was employed for the purpose of finding placement for Resident 1 closer to her family.
In a concurrent interview with the DON on 10/06/16 at 2:55 p.m., she reported Resident 1 was discharged to the care of the RBO. The DON reported facility nursing staff demonstrated to the RBO how to administer Resident 1's insulin to her.
In a concurrent interview with the SSD, she reported she contacted the PA operator (PAO) to determine if the PAO could find placement for Resident closer to her family. She reported she told PAO that Resident 1 needed help with her Activities of Daily Living (ADLs: moving, dressing, toileting, and others) but she did not explain to PAO that Resident 1 was insulin dependent. It was the understanding of the SSD that the RBO was a private individual who had agreed to take Resident 1 into his home and provide his care.
In an interview with the PAO on 10/10/16 at 9:10 a.m., she was asked what the differences were between a R&B and a Board and Care (B&C) facility. She reported a B&C could provide care and medication management. She stated a R&B was for "more independent people." The PAO was aware the Resident 1's income was not enough to cover the expenses of a licensed B&C provider. The PAO reported she was not aware Resident 1 required the use of a lift to transfer her from her bed to her wheelchair, or she was insulin dependent. A lift is a mechanical device, which often suspends the entire body weight of a person in a sling, to aid in transferring the patient between two surfaces such as a bed and chair. Insulin dependency requires daily, or more frequent, injections of insulin (a medication to treat imbalances in the amount of sugar found in the blood.)
In an interview with the RBO on 10/10/16 at 9:45 a.m., he reported he had a business license for the purposes of operating a R&B. He reported the R&B provided a room and meals, but no other care. He denied the facility staff had taught him how to administer the insulin. He reported he was unaware of her high care needs. He reported that after the van brought her to his home it was discovered she could not get in through the door and she had to be left in the garage. She became upset, defecated on herself and then set herself on the floor where she remained because he had no means to lift someone of her size off of the floor. He reported she was only at his home for approximately 2 hours before he called 911 to have her taken to the emergency room.
In subsequent interview with RBO on 10/10/16 at 12:15 p.m., he reported he made an agreement with the facility for the facility to pay him $2,000 a month for Resident 1's social security payments, which were being paid to the facility. He reported the facility agreed to continue paying for a total of three months. The RBO stated that when Resident 1 was sent to the emergency room, the ADM requested the RBO return the money.
In an interview with the ADM on 10/12/16 at 3:10 p.m. he was asked how Resident 1's needs could not be met at the facility, as indicated on the Notice of Transfer/Discharge, and he reported Resident 1 was unhappy because she was too far from her family and she refused care. The ADM reported the discharge was appropriate because the OMB and the RP were present and neither of them protested the transfer.
In an interview with the SSD on 10/12/16 at 3:30 p.m., she reported a R&B typically cost approximately $600 a day, and a B&C costs began at approximately $2500. She stated Resident 1 needed 24/7 care and medication management. This demonstrated the R&B was paid a sum of money nearly equal to what would be charged for a B&C for care equal to what would be provided in a B&C.
In an interview with the OMB on 10/13/16 at 1:15 p.m., she reported she had attended the meeting to provide support to the RP, but she had no direct knowledge of Resident 1's care needs. It was explained to her that Resident 1 qualified for a lower level of care and placement had been found that could provide that care. She reported she was unaware Resident 1 was insulin dependent and had very high care needs. The OMB stated "I assumed it was a care facility for a lower level of care...I assumed it was a licensed care provider."
In an interview with RP 1 on 10/13/16 at 2:05 p.m., he reported he did attend the Discharge Meeting on 10/3/16, by telephone. He reported he was told Resident 1 would be going to get the same exact care she was getting at the nursing facility, that someone would be providing her care 24/7. RP 1 reported he had been assigned the RP by Resident 1, however he was not medically knowledgeable. When asked if he felt he had the knowledge and experience to make medical decisions for Resident 1 he replied "No." He reported he was assured the RBO was qualified to provide the care and he was unaware the RBO was not a licensed care provider.
The Department determined the facility failed to ensure Resident 1 was transferred to a safe location when she was discharged to a Room and Board facility not equipped to meet the high medical needs of Resident 1. As a result of this failure, Resident 1 was at risk of injury or neglect.
These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility residents. |
| 100001316 |
RCCA - GATEWOOD DRIVE HOME |
040009231 |
B |
23-Apr-12 |
HVVC11 |
5770 |
Title 17 50510 (a) (8) 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) Acces 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 physical abuse when Client B was found by staff on top of Client A; with Client A's brief (disposable underwear) pushed to the side and Client B's pants down, as Client A napped in her room. Entity Reported Event # CA00293868 was investigated during an onsite visit on 12/29/11. Client A's "Comprehensive Functional Assessment" (assessment of the client's overall abilities) dated 4/18/11, indicated Client A required assistance for all ADLs (activities of daily living) care as well as nursing care. Client A's "Consumer Profile" (identified the client's diagnoses and basic skills) dated 9/15/11, indicated Client A was non verbal, non ambulatory and required staff assistance to reposition. The facility's Investigative Report dated 12/29/11, indicated that on 12/22/11 "...[Client A] was asleep in her bed and [Client B] was in his bedroom taking his keys and bells off. [Items he wore on his clothes] because [Client B] usually removes his bells and keys prior to resting...[Client B] indicated he was going to take a nap. At about 2:41 p.m., Staff 1 asked Staff 2 to watch the clients while she took a short break and went outside. At about 2:45 p.m. Staff 2 went to the back of the house to check on the clients...Staff 2 found [Client B] in [Client A's] room doing what appeared to be attempting to engage in non-consensual intercourse with [Client A]..." On 12/29/11 at 1030 a.m., during an interview, the Qualified Mental Retardation Professional (QMRP) stated two staff (Staff 1 and Staff 2) had been working on the day of the incident (12/22/11). The QMRP stated [Client A] was in her room in bed and [Client B] told Staff 1 he was going to rest in his room. Staff 1 went to take a break. When Staff 2 went to check the clients she found [Client B] (in Client A's room) on top of [Client A]. Client B stated, "I'm in big trouble now" as he exited [Client A's] room. The QMRP further stated, [Client B] had come to this home from a higher functioning home to receive nursing care for approximately 90 days. The QMRP stated [Client B] had been in a consensual sexual relationship in the past. On 12/29/11, at 10:45 a.m., during an interview, the QMRP stated, since the incident (where Client B was found on top of Client A); [Client A] had exhibited cowering when approached in her room and assumed a fetal position. Client A had been spending more time out of her room (away from the area where the incident occurred). The QMRP stated Client A's bed was placed in the living room when she was anxious. The QMRP stated staff requested a consent for an anti-anxiety medication (medication used to relieve anxiety) for Client A. A review of Staff 2's Declaration dated 12/23/11, revealed that on 12/22/11 (no time) she looked in Client B's room and Client B was not there. Staff 2 then looked in Client A's room where Staff 2 saw Client B (with his pants down almost to his knees) on top of Client A. Staff 2 saw that Client A's blanket was off and Client A's brief was pulled to the side. Staff 2 documented that Client B said (after being found on top of Client A), "I'm in big trouble "Big Big" trouble." Staff 2 further documented she notified the police who came and removed Client B from the facility. A review of the acute hospital's Emergency Department (ED) Provider Notes dated 12/22/11 at 4:27 p.m., revealed Client A was brought to the ED for "Suspected sexual assault or rape." The notes contained documentation that Client A had a sexual assault (SART) examination performed of her pelvic area to rule out sexual abuse. Client A was subjected to vaginal examinations which included swabbing her cervical area to rule out sexually transmitted diseases (i.e. gonorrhea and chlamydia).The facility policy/procedure titled "Abuse/Neglect/Mistreatment" dated 2/1/10, identified that physical abuse included "...sexual contact or any other form of physical contact which may result in physical harm or injury to the client..." The facility "Statement of Report Suspected Abuse" dated 6/95, indicated "it is the policy of [Facility] to ensure that all individuals are free from abuse and neglect." The facility failed to ensure Client A's right to be free from physical abuse when staff found Client B (with his pants down) on top of Client A (whose brief was pushed to the side) as Client A napped in her room. This incident resulted in Client A being subjected to a SART (sexual assault/pelvic examination) at the acute hospital. Client A became anxious exhibited by cowering and assuming a fetal position when approached by staff in her room. Staff moved Client A's bed into the living room when Client A was anxious. Staff requested a consent for the use of an anti-anxiety medication for Client A. The above violation either jointly, separately or in any combination had a direct or immediate relationship to the client's health, safety or security and therefore constitutes a Class 'B' Citation. |
| 030000088 |
RIVERBANK NURSING CENTER |
040009746 |
AA |
14-Feb-13 |
H83811 |
8155 |
Title 22 Division 5 Article 3 Section 72517 (a) (5): Each facility shall have an ongoing educational program planned and conducted for the development and improvement of necessary skills and knowledge for all facility personnel. Each program shall include, but not be limited to: Accident prevention and safety measures. The facility failed to provide an ongoing educational program which included staff instruction to follow manufacturer's safety guidelines for the use of the full body sling on the Hoyer Lift. As a result of this failure to provide this training to staff, Patient 1 fell from the Hoyer Lift when CNA 1 failed to fully engage the hooks into the swivel bar of the Hoyer Lift which led to Patient 1's serious injury, head trauma and bleeding. Patient 1 subsequently died within two days of the fall. Entity Reported Event CA 00300289 was investigated during an unannounced visit to the facility on 2/23/12. Patient 1's admission record included information that Patient 1 was a 90 year old female admitted to the facility on 4/17/10. Patient 1's diagnoses included Alzheimer Disease (Cognitive Disorder marked by confusion) and Osteoporosis (disease that weakens the bones). Patient 1's Minimum Data Set (MDS) Assessment, dated 1/3/12, indicated Patient 1 required total assistance by staff for Activities of Daily Living (ADLs) and extensive assistance with transfers. Patient 1's total dependence on staff during transfers required the assistance of a Hoyer Lift for transfer. The "Interdisciplinary Post-Fall Assessment" dated 2/19/12, indicated, two Certified Nursing Assistants had transferred Patient 1 from the wheelchair (w/c) to the bed using a Hoyer Lift. This document included information that the loop of the sling, used for Patient 1 to sit on while on the lift, came off one side of the Hoyer Lift. Patient 1 then fell to the floor and hit her head on the legs of the Hoyer Lift. Patient 1 was documented as "confused" and "disoriented." Patient 1 sustained a laceration under the chin and an injury to her nose. The document indicated Patient 1's nasal septum had been deviated to the left with blood clots in the nares. The facility called 911 for emergency transport to the acute care hospital immediately after Patient 1's fall from the Hoyer Lift. The "Nurse's Notes" dated 2/19/12 at 1:30 p.m., contained documentation, "Heard a CNA yell for help. Resident on floor face down... with face in pool of blood (sic). ABC's (Airway, Breathing, Circulation) compromised ...bleeding from chin cut, + (and) bleeding from cut above R [right] eye. Called for crash cart (cart with emergency resuscitation [reviving] supplies) ...O2 sats (blood oxygen saturation level) 80's (normal 97% - 99%) O2 applied at 2 LPM (liters per minute) simple mask, sats continued to decrease to low 70's, resident [Patient 1] became unresponsive ...placed on the bed in preparation for CPR (cardiopulmonary resuscitation) ...sats continue to drop ..." On 2/23/12 at 11:10 a.m., during a concurrent observation and interview, CNA 1 stated she had been one of the two CNAs who had transferred Patient 1 using the mechanical lift on 2/19/12. CNA 1 then demonstrated the use of the Hoyer Lift (as would be performed in the transfer of a totally dependent patient). During the demonstration, CNA 1 did not demonstrate how the mesh of the body sling would be safely engaged on the swivel bar hooks in order to prevent a fall. The sling pad used for Patient 1 had four loops with secured metal rings in each of the four corners. Each loop was color coded from the farthest to the closest proximity to the body of the sling in the order of black, pink, green and blue. CNA 1 stated all of the loops had been intact and there had been no defect or weakened part. CNA 1 stated she and CNA 2 entered Patient 1's room on 2/19/12 at 1:10 p.m. and had taken in the Hoyer lift to transfer Patient 1 from the wheelchair to the bed. CNA 1 stated the purple mesh sling had been placed on the wheelchair. Patient 1 had then been transferred to the wheelchair seat and her bottom placed on the sling pad. CNA 1 stated that CNA 2 hooked the two loops which supported Patient 1's head and upper body to the top part of the bar which held the loops of the sling. The hooks of the sling had been placed on the top part of the bar rather than the lower bar where the hooks would have been fully engaged. One loop was placed toward the left side of Patient 1's head, and the other loop to the right side. CNA 1 stated she then hooked the two loops which had supported Patient 1's lower part of the body. Patient 1 had been lifted three feet high from the ground when Patient 1's left leg slid off of the sling pad. At this time, CNA 1 stated the left lower corner of the loop of the sling had disengaged from the hook on the Hoyer Lift. CNA 1 stated she tried to grab Patient 1's leg, but Patient 1 slid, tumbled forward, and hit her head and nose on the leg of the left side wheel of the Hoyer Lift. CNA 1 stated checking the status of full engagement of sling strap had never been a part of procedures ever before, and no one ever fell off before till now. CNA 1 acknowledged the sling strap placed to support Patient 1's lower left side had been placed on the hook, but disengaged on the lower part of the bar.On 2/13/12 at 12:10 p.m., during an interview, the Director of Staff Development (DSD) stated the standard procedure for use of the Hoyer Lift, but did not include the step (from the manufacturer's guidelines) how to ensure the sling straps were fully engaged on the lowest part of the bar prior to the operation of the Hoyer lift. The manufacturer's guidelines for the Hoyer [mechanical] Lift use of the full body sling (provided by the facility's administrator on 2/23/12) indicated, "Sling straps must be fully engaged on swivel bar hooks."The facility's Lesson Plan for training provided to Certified Nursing Assistants (CNAs) dated 5/25/11 titled, "Proper Lifting + Use of Mechanical Lifts" did not include the steps of the manufacturer's guidelines for safe use of the body sling on the Hoyer Lift in order to prevent a fall. On 2/23/12 at 1:40 p.m., during a concurrent interview and observation, CNA 3 verbalized how to use the Hoyer Lift step by step, but did not describe how to ensure the sling straps would be fully engaged on the swivel bar. During a demonstration CNA 3 was observed to hook the sling strap on top of the swivel bar and did not ensure it was fully engaged. On 2/23/12 at 1:50 p.m., during a concurrent interview and observation, CNA 4 described how to use the Hoyer Lift step by step. CNA 4 did not state how she would ensure the sling straps had been fully engaged on the swivel bar prior to transferring a patient on the Hoyer Lift. During a demonstration CNA 4 was observed to hook the sling strap on top of the swivel bar and did not ensure it was fully engaged. Patient 1 was sent to the hospital on 2/19/12. A review of the "Hospitalist (MD who works in the hospital) Discharge Summary" dated 3/8/12 contained documentation, "...Patient was found to have multiple facial fractures, subarachnoid hemorrhage (bleeding in the subarachnoid space of the brain), ...and cardiac dysrhythmia ..." The facility failed to effectively instruct and follow safety guidelines from the manufacturer's guidelines for use of the full body sling on the Hoyer Lift. Patient 1 fell from the Hoyer Lift when CNA 1 failed to fully engage the hooks into the swivel bar which led to Patient 1's serious injury, head trauma and bleeding. Patient 1 died within two days of the fall. Review of Patient 1's Coroner's Autopsy Report, dated 3/13/12 indicated, " ...AUTOPSY FINDINGS: 1. Subarachnoid hemorrhage ...2. CAUSE OF DEATH: Cardiac arrhythmia due to a combination of hypertensive heart disease and blunt trauma to the head and face ..." These violations, either jointly or separately, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the patient and therefore constitutes a Class "AA" Citation. |
| 030000088 |
RIVERBANK NURSING CENTER |
040011133 |
B |
24-Nov-14 |
64XE11 |
6370 |
AMENDED 2567 12/10/2014 to include date survey completed and event ID# F 223 483.13 (b) AbuseThe resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.This requirement in not met as evidenced by: The following violation was noted during the investigation of Entity Reported Incident (ERI) number CA00414401.The facility failed to ensure each resident's right to be free from abuse, when Resident 1, was verbally abused, taunted, and slapped by Certified Nursing Assistant 1 (CNA 1).Resident 1 was a 27-year old male who was re-admitted to the facility on 9/5/14, with diagnoses including quadriplegia (paralysis of the body from the neck down), neuralgia (severe pain caused by nerve damage), anxiety (state of apprehension or fear), depression, and acute (short-term) and chronic (ongoing) respiratory failure (condition in which not enough oxygen passes from the lungs into the blood, causing shortness of breath or air-hunger). The annual Minimum Data Set (MDS) assessment (a federally mandated assessment of residents in a skilled nursing facility to identify functional abilities and health problems) dated 6/21/14, indicated Resident 1 was totally dependent on staff for activities of daily living such as repositioning in bed, dressing, eating, personal hygiene, and bathing. In addition, Resident 1's upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot) range-of motion were impaired. The Brief Interview for Mental Status (BIMS) indicated Resident 1 was alert and oriented and had correct recall of words, day, month, and year.On 10/1/14 at 1:20 p.m., Licensed Nurse 1 (LN 1) was interviewed. LN 1 stated on 9/23/14 just past midnight, CNA 1 reported to her (LN 1) Resident 1 had turned his call light on and when she answered, Resident 1 refused to receive care from CNA 1 and yelled at her to get out of his room. LN 1 stated she told CNA 1 to leave Resident 1 alone and specifically instructed her not to go back to Resident 1's room.LN 1 stated upon her return to the nursing station, she heard a loud exchange of (Spanish) words coming from Resident 1's room. LN 1 stated as she walked toward Resident 1's room to investigate what was going on, she heard CNA 1 tell the resident: "You are not gonna talk to me like that!" LN 1 stated she then heard a loud "slapping" sound. LN 1 stated she called out CNA 1's name and as CNA 1exited the room, LN 1 entered to check on Resident 1.LN 1 stated she asked Resident 1 what had happened. Resident 1 responded, "Did you hear the slapping? She slapped me!" LN 1 stated, "He looked shocked and his right cheek was reddened. He was quiet, subdued...shocked. He asked me to not allow CNA 1 to come back to his room." On 10/1/14 at 2:15 p.m., an interview with Resident 1 was conducted in his room. Resident 1 was in bed, alert and oriented. He was holding his computer tablet, but he could not lift or raise his arms. Resident 1 stated he was "paralyzed" from the neck down and relied on staff for care.Resident 1 stated he had a "special bond" with CNA 1 up until his return from the hospital on 9/5/14. He stated, "We were not officially boyfriend-girlfriend but she spent a lot of time with me on her break time 'making out,' you know, like hugging and kissing. Then she was controlling me, calling me on my phone, texting me, coming to my room all the time and I didn't like that, so I told her not to come to my room anymore." Resident 1 stated, the night of 9/23/14, he had turned his call light on. Resident 1 stated CNA 1 came to his room instead of his regular CNA. Resident 1 stated he was angry and cussed at her and told her to get out of his room and not to come back. Resident 1 stated CNA 1 left but came back and argued, cussed at him, and told him he was a 'pathetic loser,' and he shouldn't treat her like s-t because he needed her to take care of him. Resident 1 stated CNA 1 told him not to ever talk to her like that again and then slapped him hard on his right cheek. Resident 1 stated, "I was defenseless and felt so helpless, I could not bend my elbows or raise my arms to protect myself. My cheek 'stung' from the force of her slap and I was shocked at what she did."On 10/1/14 at 2:40 p.m., the Social Services Notes dated 9/25/14 was reviewed. The notes reflected; "Resident has been thinking about the incident...stated, "I feel 90% disrespected and 10% guilty. I just wished she stayed out of my room and this would not have occurred. I just can't believe she hit me."On 10/1/14 at 2:43 p.m., the facility's investigation report dated 9/30/14 reflected in part: "On 9/23/14 on the night shift, (CNA 1) answered (Resident 1's) call light and he asked her to get his assigned CNA for him. He did not want (CNA 1) to take care of him... A little later, his call light was on again and (CNA 1) answered it and he told her to leave his room and stay away from him. He cursed at her...and she cursed back at him and then walked to his bedside and slapped him on his right cheek with her open left hand. The charge nurse (LN 1) was at the nurse's station and heard them yelling in Spanish and was coming to the room to see what was happening and heard the smack of the slap right before she entered the room..." On 10/1/14 at 2:45 p.m., during interview, the Administrator stated that when she interviewed CNA 1 to get her side of the story, CNA 1 did not confirm nor deny that she slapped Resident 1 and repeatedly stated she didn't want to "remember." The Administrator stated, "I did not need her confirmation: I had the staff's and Resident 1's credible account of what happened.The facility failed to ensure each resident's rights to be free from abuse when Resident 1, who was paralyzed and dependent on staff for his total care and well-being, was verbally, emotionally, and physically abused by CNA 1. Resident 1 had asked and rejected CNA 1's presence in his room, and CNA 1 deliberately returned to the resident's room against LN 1's instructions. CNA 1 willfully engaged in verbal altercation with Resident 1 which ultimately resulted to CNA 1 slapping him on his cheek. CNA 1's action inflicted physical pain and emotional unrest to Resident 1.This violation had a direct relationship to the health, safety, or security of Resident 1 and constitutes a Class B Citation. |
| 040000012 |
RAINTREE CONVALESCENT HOSPITAL |
040013169 |
B |
28-Apr-17 |
26GM11 |
11050 |
F 206 483.15 ? (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 ? as they apply to discharges.
?(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.
On 2/2/17 an unannounced visit was made to the Skilled Nursing Facility (SNF) to investigate complaint CA00518922 regarding an alleged violation of transfer/discharge rights.
The facility failed to permit Resident 1 to return to the SNF to the first available bed following hospitalization when Resident 1 was cleared for discharge from the acute care hospital and a facility bed for the same gender was available but not offered to Resident 1.
This failure prevented Resident 1 from returning to the SNF, which had been his long term residence, and resulted in an extended acute care hospital stay. Resident 1 expressed feelings of stress, anxiety, depression and frustration as a result of displacement from his residence, usual routines and extended confinement in the acute care hospital.
Review of Resident 1's clinical record titled, "Admission Record" ( document containing resident personal information), indicated Resident 1 was admitted to the SNF on XXXXXXX12 with diagnoses that included "Blindness, Both Eyes, Type 2 Diabetes Mellitus [disorder which causes high blood sugar due to insufficient production of the hormone insulin which regulates blood sugar], End Stage Renal Disease [kidney failure], Major Depressive Disorder [persistent altered mood including feelings of hopelessness and worthlessness], Anxiety Disorder [disorder characterized by feelings of apprehension, worry, uneasiness and dread] and Convulsions [seizures]." The Admission Record indicated Resident 1's primary language was Spanish.
On 1/31/17, during a telephone interview, the acute care hospital (ACH) 2 Case Manager (CM) 1, stated Resident 1 had been admitted to ACH 2 on XXXXXXX17. CM 1 stated Resident 1 had resided at the SNF for several years prior to admission to ACH 2 and wanted to return to the SNF. CM 1 stated Resident 1 had been cleared for discharge back to the SNF on XXXXXXX17. CM 1 stated she phoned the SNF and was informed by the Director of Nursing (DON) there were no male beds available in the SNF at that time. CM 1 stated Resident 1 was legally blind and on hemodialysis (a procedure to clean the blood of waste products using an artificial kidney when the resident's kidneys have failed). CM 1 stated she informed the DON on 11/21/17 Resident 1 wanted to return to the SNF and be placed in the first available bed. CM 1 stated the SNF, though the SNF staff knew Resident 1 wanted to return to the SNF when discharged from ACH 2, later gave away the first available male bed to another resident.
On 2/2/17 at 9:55 a.m., during a concurrent interview and clinical record review, the SNF Assistant Director of Nursing (ADON) reviewed Resident 1's record and stated Resident 1 was transferred to ACH 1 on XXXXXXX16 and had a seven day bed hold (a resident's right to hold the bed at the SNF for seven days while in the hospital for treatment). The ADON stated Resident 1 left ACH 1 against medical advice and went to the emergency room at ACH 2 where he was admitted as an inpatient. The ADON stated that she was informed by ACH 2 on 11/21/16 Resident 1 was clear for discharge and wanted to return back to the SNF. The ADON stated Resident 1 was still in ACH 2. The ADON stated there had been two male beds available at the facility during the time Resident 1 was in ACH 2, but ACH 2 had not been informed of the availability of the beds by the SNF. The ADON stated according to the SNF policy and procedure she should have informed ACH 2 of the bed availability and provided the first male available bed to Resident 1, but she did not.
On 2/2/17 at 12:45 p.m., during an interview, the SNF Administrator (Admin) stated the SNF had an open available male bed in December 2016, but she had the impression that Resident 1 had been discharged to another facility. The Admin stated the facility received a call on 1/18/17 from CM 1 to see if a male bed was available for Resident 1. The Admin stated she told CM 1 that one male bed was available, but it had already been promised to a new resident. The Admin stated a new resident was admitted to the empty bed on XXXXXXX17.
On 2/17/17 at 10:25 a.m., during an observation and concurrent interview at ACH 2, Resident 1 was lying in bed in his room. Resident 1 was alert and spoke through a Spanish speaking translator. Resident 1 stated he lived at the SNF for six years before he was admitted to ACH 2. Resident 1 stated he was legally blind and could see only shadows. Resident 1 stated he found it difficult to adapt to new environments due to his visual difficulties. Resident 1 stated he wanted to return to the SNF where he was familiar with the staff, environment and routines. Resident 1 stated when he felt under stress or anxiety at the SNF he would go outside to the patio area and walk around in fresh air which helped relieve his stress. Resident 1 stated he was not permitted to walk outside at ACH 2. Resident 1 stated at the SNF he enjoyed the activities and sitting outside with friends, but was not able to do those things at ACH 2. Resident 1 stated he felt stress, anxiety, depression and frustration due to his long hospitalization and lack of exercise and activities.
On 2/17/17 at 11:25 a.m., during an interview and concurrent resident census review, the ADON stated a blank area on the daily census report meant the resident room was empty. The ADON stated room [?] was empty from 11/29/16 to 12/5/16 and room [?] was empty from 1/5/17 to 1/18/17. The ADON stated the census indicated there was an open male bed available for admission during those dates but the SNF did not notify ACH 2 of the bed availability. The ADON stated on 1/16/17 she talked to CM 1 from ACH 2 and informed CM 1 that facility had one open male bed available but it was promised to another resident who was not from their SNF. The ADON stated she was not aware of the SNF policy or the legal requirement to re-admit the resident to the first available bed when she spoke with CM 1 on 1/16/17. The ADON stated she should have given the first available male bed to Resident 1 according to the SNF policy.
Review of Resident 1's case manager liaison notes from ACH 2 dated 10/6/16, indicated, "?Writer called [SNF] and spoke with [ADON]. [ADON] reported that patient was once a resident there? [ADON] reported that patient's bed hold is expired and there are no longer beds available at [SNF]."
Review of Resident 1's case manager notes from ACH 2 dated 10/10/16, indicated, "Spoke to [ADON] at [SNF]?and she confirmed patient is long term patient that lost bed last week. Advised [ADON] per MD [doctor] possible d/c [discharge] this Thursday or Friday. She said to call back because at this time no LTC [long term care] bed available."
Review of Resident 1's case manager notes from ACH 2 dated 10/13/16, indicated, "Called [ADON] at [SNF] and she said no bed available and no pending d/c at this time. She said to check on a weekly basis."
Review of Resident 1's case manager notes from ACH 2 dated 11/7/16, indicated, "Phone call to [SNF] who reports no beds available today."
Review of Resident 1's case manager notes from ACH 2 dated 12/1/16, indicated, "?spoke with [Admin] at [SNF] and asked if there is a male bed for the patient to return to. She stated no male beds at this time?"
Review of Resident 1's case manager notes from ACH 2 dated 12/2/16, indicated, "?spoke with [ADON] at [SNF] and they will take the patient back once a male bed opens up."
Review of Resident 1's case manager notes from ACH 2 dated 12/13/16, indicated, "? [SNF] continues with no male bed."
Review of Resident 1's case manager notes from ACH 2 dated 1/20/17, indicated, "?spoke with [ADON] at [SNF] and she states they had an open male bed but filled it and did not have to hold it for [Resident 1] since he was past his 7 day bed hold."
Review of Resident 1's clinical record from ACH 2, titled, "[ACH 2] Skilled Nursing Patient Placement Inquiry Form," dated 1/30/17, indicated Resident 1 was admitted on 9/30/16 for complications related to hemodialysis and was ready for discharge back to the SNF on XXXXXXX17. The record indicated Resident 1 was still awaiting placement at a SNF.
The administrative document titled, "[SNF] - NEW Detailed Census Report By Payer" dated November and December 2016 and January 2017 indicated, there was one male bed available from 11/29/16 to 12/4/16 and from 1/4/17 to 1/18/17.
On 3/23/17 at 11:25 a.m., during a telephone interview, CM 2 stated Resident 1 was still at ACH 2 awaiting placement at the SNF. CM 2 stated Resident 1 had been cleared for discharge back to the SNF in XXXXXXX of 2016.
The SNF policy and procedure titled, "Readmission to the Facility" dated 2013, indicated, "1 ?resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed?"
The SNF "Admission Agreement" dated 5/11, indicated, "VII. Bed Holds and Readmission ?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 ?"
Therefore, the facility failed to readmit Resident 1 to the first available bed following hospitalization. Resident 1 expressed feelings of increased stress, anxiety, depression and frustration due to his extended ACH stay and his inability to return to the SNF and resume his usual routines and activities.
This failure had a direct relationship to the health, safety and security of Resident 1 and thus constitutes a class "B" citation. |
| 060000134 |
REGENTS POINT - WINDCREST |
060011068 |
B |
13-Oct-14 |
SCXJ11 |
3873 |
Health & Safety Code - 1424(f)(2) / Willful Material Falsification (WMF) Facility staff willfully falsified the Weekly Summary notes for Patient 5. Patient 5 developed an unstageable (full thickness tissue loss obscured by slough-yellow/brown dead tissue) pressure sore on his right heel. Patient 5 was admitted on XXXXXXX, with a physician's order to reposition the patient every two hours and to off-load heels (float heels off mattress). On 8/29/14, copies of Patient 5's Weekly Summary notes were obtained. The Weekly Summary notes from 11/27/13 through 1/3/14, showed the areas where staff were to document the resident's "skin conditions" including current skin problems, pressure relieving devices, turning and repositioning, and nutritional interventions were blank. However, on 9/22/14, copies of the same Weekly Summary notes from 11/27/13 through 1/3/14, now showed staff had filled in the blank areas. Findings: On 8/27/14, during an interview, LVN 2 identified Patient 5 to have an unstageable pressure sore to his right heel. LVN 2 stated Patient 5's pressure sore was being treated by an outpatient wound care clinic weekly. Health record review for Patient 5 was initiated on 8/27/14. Patient 5 was admitted to the facility on XXXXXXX, with status post right hip replacement. Review of the physician's Transfer Orders from the acute care hospital dated 11/21/13, showed Patient 5 had a right hip surgery on 11/18/13. The patient required assistance with turning side to side every two hours and to provide preventative skin care "lotion to heels twice a day, keep heels off mattress." Review of the Admission Nursing Evaluation form dated 11/21/13, showed Patient 5 was status post right hip surgery and had 19 staples along the incision site. The patient required assistance with bed mobility and transfers. There was no documentation the patient had any redness or pressure sores to his heels. Review of Minimum Data Set (a standardized assessment tool) dated 11/28/13, showed Patient 5 was alert and able to make his needs known. He required extensive assistance of two persons for bed mobility, transfers and toileting. He was non-ambulatory and dependent on staff for bathing. Staff identified Patient 5 to be at risk for developing pressure sores. On 8/28/14 at 1445 hours, Patient 5 was observed in bed with a heel protector (a soft padded heel cushion) applied to his right heel which was resting on the mattress. His left heel was resting on the mattress and had no heel protector. Patient 5 was asked if he was able to reposition himself in bed. He stated he could not turn without the assistance from staff. On 8/29/14 at 0915 hours, an interview and concurrent health record review was conducted with LVN 2. LVN 2 confirmed there were no documented interventions to address pressure relief for Patient 5's heels until after the heel pressure sore developed. The LVN was asked where the staff documents their weekly skin assessments. She stated in the licensed nurse Weekly Summary notes. Review of the Weekly Summary notes showed an area where the nursing staff were to document the patient's "skin conditions" including current skin problems, surgical wounds, pressure relieving devices, turning and repositioning, and nutritional interventions. However, all of these areas were blank from 11/27/13 through 1/3/14. On 9/22/14, additional copies of Patient 5's health record were received from the facility. Among the documents were copies of the same Weekly Summary forms dated 11/27/13, 12/4, 12/10, 12/18, 12/27/13, and 1/3/14. However, now the blank areas were filled in. On 10/3/14, a telephone interview was conducted with the facility's Administrator and DON. Both were unable to explain how Patient 5's health record had been altered. These failures have a direct and immediate relationship to the health, safety or security of patients. |
| 070001398 |
ROUNDTREE HOME |
070012377 |
B |
11-Jul-16 |
DIV911 |
4579 |
Welfare & Institutions Code 4502(H) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to ensure one client (Client 1) was free from verbal abuse and treated with dignity and respect by direct care staff B (DCS B) when DCS B said derogatory words towards Client 1. Verbal abuse can decrease self-esteem and cause mental anguish. Client 1's comprehensive functional assessment dated 5/5/15 indicated she was non-verbal, and could communicate her needs through body language and hand gestures. She was ambulatory and required assistance with her activities of daily living. She had a diagnosis of developmental delay. The facility's investigative report dated 6/16/16 indicated DCS A witnessed DCS B saying derogatory words to Client 1. The investigation summary of the incident indicated one staff positively witnessed DCS B saying derogatory remarks to Client 1. During an observation on 6/23/16 at 10:30 a.m., at the day program (DP) Client 1 was seated in her wheelchair working a table top activity. When greeted, she responded to the surveyor though vocalization and hand gestures. During an interview on 6/23/16 at 2:00 p.m., DCS C stated whenever she worked with DCS B, DCS B would talk loudly to Client 1 and call Client 1 names "hey Lola" (meaning grandma). DCS C stated DCS B talked in a loud and scolding voice but she thought that was her normal way. DCS C stated she spoke to DCS B numerous times to lower her tone of voice when talking to the client but DCS B continued to use the same tone of voice. DCS C stated DCS B called Client 1 "stupid." DCS C acknowledged DCS B was mean and rude to Client 1. During a telephone interview on 6/23/16 at 3:40 p.m., DCS E stated she had worked with DCS B the month of June 2016. She stated during her shift she had witnessed DCS B being rude and mean to Client 1 and called her "stupid" and "crazy." This occurred during activities of daily living, i.e., toileting, feeding, and recreation time. DCS E stated DCS B was verbally abusive to the client on a daily basis. She stated on 6/14/16 she reported DCS B's abusive behavior to the qualified intellectual disabilities professional (QIDP). During a telephone interview on 6/23/16 at 4:17 p.m., DCS A stated DCS B had a loud voice when she talked to Client 1. DCS A stated sometimes during feeding Client 1 did not want to eat and DCS B would call the client "stupid" and "crazy." He stated DCS B would also use those words when Client 1 showed symptoms of agitation, i.e., slapping her face. He stated DCS B was rude to Client 1, talked to the client in a condescending tone, and did not treat her with respect. During a telephone interview on 6/28/16 at 8:55 a.m., the QIDP stated upon investigation, "the incident was definitely patient abuse." She stated she reported the incident to the law enforcement agency, the regional center, and the facility licensee. A review of the facility's undated policy, "Abuse Prevention and Reporting" and "Rights of Persons With Developmental Disabilities" indicated: It is the intent of the legislature that persons with developmental disabilities shall have rights including, but not limited to the following: "A right to be free from harm including abuse..." The provider has the capacity to detect and prevent the clients from abuse and neglect, and reviews specific incidents for "lesson learned" which forms a feedback loop to affect necessary policy changes. "The provider seeks generally to support families, staff and clients. Additionally the provider makes an effort to protect clients from abuse and neglect...." The facility failed to ensure Client 1 was free from verbal abuse when DCS A spoke loudly, used derogatory words, and name calling targeted at Client 1 who was non-verbal and medically compromised. The above violation caused or occurred under circumstances likely to cause low self-esteem and humiliation. |
| 070001028 |
RCCA - CAMINO VERDE |
070013420 |
B |
18-Aug-17 |
OPY411 |
6427 |
W438 - 483.470(h)(1) EMERGENCY PLAN AND PROCEDURES
The facility must develop and implement detailed written plans and procedures to meet all potential emergencies and disasters such as fire, severe weather, and missing clients.
The facility failed to ensure a detailed plan and procedure to meet all potential emergencies was developed and implemented for six of six sampled clients (Clients 1, 2, 3, 4, 5, and 6) when bedbugs were found in Client 1's bed and all clients were relocated during the night to a hotel and transferred to a second hotel the following day. This failure resulted in missed scheduled activities for all the clients; missed lunches for three clients (1, 2, and 3) on 7/27/17; and missed or late afternoon medication administration for three clients (4, 5, and 6).
During an observation of the facility on 7/27/17 at 9:00 a.m., direct support professional A (DSP A) was in front of the facility sitting in a van.
In a concurrent interview, he stated the clients were not in the facility.
During an interview with the residential manager (RM) at 9:05 a.m., she stated the clients were transferred to a hotel during the night of XXXXXXX 17. The RM stated a school staff called on 7/26/17 at 11:00 a.m., informing the facility a bedbug (parasitic insects that feed exclusively on human blood) was found in Client 1's wheelchair. The RM stated they picked Client 1 up from the school, and as soon as Client 1 arrived at home, the facility stripped and checked his bed and wheelchair. The RM stated the facility found two more bedbugs in Client 1's bed, but nothing was found in the other clients' beds or wheelchairs. The RM stated the facility also washed and dried all the linens on a higher heat temperature. The RM stated management instructed them to evacuate the clients to a hotel.
During a visit to the hotel where the clients were transferred on the same day at 9:45 a.m., the clients were assigned to three rooms. Room A's door was opened and there were two clients (Client 4 and Client 6) in separate beds, but nobody was supervising them when the surveyor arrived. A large opened box containing the clients' medications was observed on the table. DSP B was seen walking in the hallway.
During a concurrent interview with DSP B, she stated she was supposed to watch Client 4 and Client 6 in Room A but she stepped out from the room for a few minutes.
Room B and Room C were next to each other with DSP C in Room C. In Room C, two opened boxes of food were observed on the floor. A half full gallon of milk and a 32 ounce container of vanilla yogurt were observed in one of the boxes. There was no refrigerator observed in the rooms. At approximately 10:30 a.m., DSP A joined the two staff in the hotel.
In an interview with DSP C, she stated Client 1 had no bedbug bites on his body. A visual skin observation of Client 1's skin was completed and no trace of bedbug bites was found.
During an interview with DSP A at 10:30 a.m., he acknowledged he was out of the hotel for a few minutes and only two staff were there to supervise six clients in three different rooms.
During an interview with the qualified intellectual disabilities professional (QIDP) on 7/27/17 at 10:42 a.m., he acknowledged the clients were moved during the night due to two bedbugs having been found in Client 1's bed. The QIDP confirmed the clients missed their school (Client 1 and Client 6) and day program schedule (Clients 2, 3, 4, and 5) on 7/27/17.
On 7/27/17 at 12:00 p.m., a concurrent interview with the QIDP and record review of the facility's emergency binder, "Emergency Information", indicated to move the clients across the street during an emergency evacuation and if emergency shelter was needed the clients would be relocated to a high school in the area. The QIDP acknowledged there was no arrangement made for an alternate place to relocate the clients in case of emergency evacuation, other than a high school as written in the binder.
The QIDP also stated the clients would be relocated to a new hotel with refrigerators for the perishable food brought from home as soon as an arrangement was finalized. The QIDP stated the facility van could only accommodate three clients at a time.
During observations on 7/27/17 at approximately 12:00 p.m., Clients 4, 5, and 6 were transferred temporarily to a sister facility for showers and then would go to the new hotel. Clients 1, 2, and 3 stayed behind in the hotel until the van picked them up to go to the new hotel. The clients (1, 2, and 3) missed lunch because the food was boxed with the clients who went to the sister facility.
At approximately 4:30 p.m., Clients 1, 2, and 3 were settled in the new hotel in their rooms and dinner was served. Clients 4, 5, and 6 arrived at the new hotel at approximately 6:00 p.m. Client 4's medication which was due at 3:00 p.m., was missed, Client 5's medication which was due at 4:00 p.m., was given late, and Client 6's medications which were due at 4:00 p.m. and 5:00 p.m., were given late.
During a concurrent interview with the QIDP, he acknowledged the three clients (1, 2, and 3) did not receive their lunch. Client 3 was observed to consume his dinner very fast when it got served to him.
During an interview with the licensed nurse (LVN) at 6:30 p.m., she acknowledged Client 4's Tizanidine, 20 milligram (mg) tablet (a muscle relaxant) due at 3:00 p.m., and Gavilax ,17 gram (to treat constipation), were given late while the Baclofen, 20 mg (treat muscle spasm), due at 3:00 p.m., was missed. Client 5's Lamotrigine (anti-epileptic medication used to treat seizures) due at 4:00 p.m. was given at 6:00 p.m.; Calcium tablet (supplement) due at 4:00 p.m. was given late; and Client 6's Diazepam 5 mg tablet (to treat anxiety), due at 4:00 p.m., was given two hours late.
A review of the facility's policy and procedure, "Disaster and Mass Casualty Plan and Emergency Information", on 8/2/17, indicated the facility will work with their regional center service coordinator to determine possible alternative emergency relocation sites. Specific employee assignments will be made for which emergency items should be gathered, so no critical items would be left behind. Medications will be the first priority because it may be critical to a client's health.
This violation had a direct relationship to the health, safety, or security of clients. |
| 080000052 |
RANCHO VISTA |
080011187 |
A |
17-Feb-15 |
ES0Q11 |
15331 |
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: 1. Notify and update the physician for 1 resident (Resident 1) when Resident 1 had respiratory distress, abnormal vital signs, and abnormal respiratory assessment. 2. Identify Resident 1's code status and administer CPR to Resident 1 when he was found unresponsive, not breathing, and without a pulse, according to Resident 1's POLST. 3. Follow the facility's policy and procedure for identifying the code status for 21 of 21 sampled residents and maintain a DNR master list in each Medical Administration Record MAR and Treatment Administration Record TAR. As a result, Resident 1 did not receive CPR when he stopped breathing, even though his POLST indicated he wanted full resuscitative measures. In addition, there was potential for other residents advanced directives not to be honored in the event they were found unresponsive. Findings: 1. Resident 1 was admitted to the facility on 7/20/14, with diagnoses which included chronic bronchitis and bronchiectasis, according to the Physician's orders. Resident 1 had the capacity to make his own decisions and wished to receive CPR if he was found to have no pulse and was not breathing, according to the POLST signed on 7/20/14. During an interview on 7/24/14 at 2:15 P.M., Licensed Nurse (LN 6), who was a Registered Nurse, stated, she was the RN on duty 7/21/14, and the LNs should have called her to assess Resident 1 when he had increased respirations. LN 6 further stated it was her understanding that LVNs were to collect data and notify a RN when there was a problem with a resident. LN 6 further stated, the LNs did not notify her Resident 1 was having respiratory distress. During an interview on 7/24/14 at 4 P.M., LN 3 stated, on 7/21/14 at approximately 11 A.M., LN 4 asked her to call Resident 1's physician and request an order to suction Resident 1 and administer a breathing treatment. LN 3 stated she spoke with the Nurse Practitioner and received an order for oral suction and Duoneb treatment. LN 3 stated, LN 4 asked her to assist in suctioning Resident 1. LN 3 stated, when she observed Resident 1, he was talking but gurgling when he spoke. He was breathing approximately 40 breaths per min (normal respiratory rate in adult male is 12-16 breaths per min) and his respirations were labored. LN 3 stated, she suctioned Resident 1 using a 14 french suction catheter in order to "get further down". LN 3 stated she suctioned "a lot" of yellow secretions and afterward, Resident 1 said he felt better. LN 3 stated, after Resident 1 was suctioned, Resident 1's respiratory rate decreased to approximately 30 breaths per min. LN 3 stated she should have notified the RN on duty that Resident 1 was having respiratory distress and did not. LN 3 further stated she did not notify the physician of the results of the suctioning because she thought Resident 1 was better. During an interview on 7/25/14 at 4:10 P.M., LN 1 stated on 7/21/14 at approximately 3 P.M., Resident 1 was "breathing hard" and looked pale. LN 1 stated Resident 1 complained that it was hard to breathe. LN 1 stated he administered a Duoneb breathing treatment and after the breathing treatment, Resident 1 was not as pale and his breathing was not labored. LN 1 could not remember Resident 1's respiratory rate after the breathing treatment. LN 1 stated he did not call the physician to notify him of Resident 1's respiratory distress and did not notify the RN on duty. Resident 1's clinical record contained no documentation of LN1's assessment of Resident 1's condition or that Resident 1 was given a breathing treatment. During an interview on 7/28/14 at 3:30 P.M., LN 4 stated, on 7/21/14 approximately 10:30 A.M., Resident 1 was having a hard time breathing and needed to be suctioned so she asked LN 3 to call the physician and obtain an order for suctioning. LN 4 states she used a Yankauer suction device and suctioned yellowish green mucus from Resident 1's throat. LN 4 stated after she suctioned Resident 1, his respirations were approximately 20-24 times per min and Resident 1 still sounded "somewhat congested and rattling." LN 4 stated, at approximately 12 P.M., she administered a Duoneb breathing treatment to Resident 1 and, after the treatment, Resident 1 was "still breathing a little fast" at 24 breaths per min. LN 4 stated she did not notify the physician of the results of the suctioning or breathing treatment because she felt the resident was stable. LN 4 further stated she did not notify the RN on duty of Resident 1's condition. LN 4 stated, she did not document in Resident 1's clinical record her assessment, vital signs, or administration of a breathing treatment. During an interview on 7/29/14 at 3:15 P.M., the DON stated, she was at home and unable to come to work on 7/21/14. The DON further stated, the staff did not call and notify her of Resident 1's change in condition and she should have been notified. During an interview on 8/12/14 at 12 P.M., the NP stated, on 7/21/14, LN 3 called her and asked for an order to suction Resident 1 and LN 3 also said Resident 1 sounded wheezy. The NP stated, she gave LN 3 an order for oral suction and Duoneb breathing treatment. The NP stated she was unaware Resident 1's respiratory rate was 40 breaths per min. The NP stated, if she had been told Resident 1 was breathing that fast, she would have sent Resident 1 to the ER to be assessed. The NP further stated, a respiratory rate in the 30s is not a therapeutic response to suctioning and Duoneb treatment and the LNs should have notified her of Resident 1's condition after the treatment. The NP stated she was unaware Resident 1 continued to have an increased respiratory rate or continued respiratory distress throughout the day on 7/21/14, and she should have been notified.According to the Licensed Nurses Progress Notes, documented by LN 3, dated 7/21/14 at 11:30 P.M, "...Respirations from 26 to 40 bpm with labored resp. (respirations) Receive order for suction for increased rattled congestion with relief. Suctioned yellow-white secretions. Receive order for Duoneb breathing tx q 4 PRN for SOB/Wheeze... Duoneb tx done with there.(therapeutic) effect. Respirations 34 bpm 02 sats 94% with 3L nasal cannula..." There were no entries in the clinical record regarding suctioning, vital signs, or administration of breathing treatments, on 7/21/14 by LN 1 or LN 4. According to the Vital Signs and Weight Record dated 7/21/14, LN 3 documented, "7-3... Respirations =40...O2 sats = 94%..." There were no other entries on 7/21/14 in the Vital Signs and Weight Record. According to the facility's Policy and Procedure entitled, Change in Resident Condition dated 3/26/07, "... Any change in signs and symptoms by a resident will be communicated to the physician promptly. The Licensed Nurse in charge will notify the physician AT ONCE or call 911 if the situation is life threatening. .." According to the facility's policy and procedure entitled, Notification of Changes, dated 7/27/08, "... should be communicated to the physician- any changes in their medical condition...SOB... then, document the following in the medical record- a. the change that has occurred b. who was notified c. physician response..." 2. On 7/25/14 at 4:10 P.M., LN 1 stated, Certified Nursing Assistant (CNA 1) came to him on 7/21/14 at approximately 5:28 P.M., and said, "there was a problem with Resident 1." LN 1 stated, Resident 1's eyes were fixed straight ahead and both hands were on his chest when, suddenly, his hands dropped down. LN 1 stated Resident 1 was very pale and was not speaking. LN 1 stated he then told CNA 1 to obtain a blood pressure and oxygen saturation on Resident 1 but no numbers registered on the machine so they tried with another machine. LN 1 stated, when they could not obtain a blood pressure or oxygen saturation on the second machine, he checked Resident 1's pulse. LN 1 stated Resident 1 did not have a pulse. LN 1 further stated, he then left Resident 1's room, went to the nursing station, and called Resident 1's wife and informed her that Resident 1 had passed away. LN 1 stated he has received training from the facility on what to do when a Resident was not breathing and did not have a pulse. LN 1 stated, "We should check the pulse and call for help. Then we should check the chart for the POLST and start CPR if they want." LN 1 stated he did not call for help or check the POLST. LN 1 further stated, "It happened so fast, I didn't remember if he was a full code. LN 1 stated LN 2 told him Resident 1 was a full code after Resident 1's wife had arrived which was approximately 6 P.M, approximately 30 minutes after Resident 1 was found by CNA 1. On 7/28/14 at 2:50 P.M., LN 2 stated, at approximately 5:30 P.M., she overheard LN 1 saying that Resident 1 had passed away and she asked LN 1 if Resident 1 was a DNR. LN 2 stated, LN1 said that Resident 1 was a DNR. LN 2 further stated, around 6 P.M., she looked at Resident 1's chart and saw the POLST indicated that Resident 1 was a full code. LN 2 stated, she reviewed the POLST with LN 1 and LN 1 was surprised when he found out Resident 1 was a full code. LN 2 further stated, it was too late to start CPR at that time as Resident 1's wife was already notified of Resident 1's death.On 7/28/14 at 4:40 P.M., Certified Nursing Assistant (CNA 1) stated, she entered Resident 1's room at approximately 5 P.M. on 7/21/14 and noticed, "He (Resident 1) looked different." CNA 1 stated, Resident 1 was breathing, but he was staring ahead and did not respond when she spoke to him. CNA 1 stated, she then left the room and told LN 1, "Resident 1 didn't look right." CNA 1 stated she and LN 1 returned to Resident 1's room and she attempted to obtain a blood pressure and oxygen saturation on Resident 1, but no numbers registered on the machine. CNA 1 stated, LN 1 instructed her to go and get a different machine and try again, but no numbers registered using the second machine. CNA stated, LN 1 then checked Resident 1's pulse. CNA 1 further stated, LN1 told her "he (Resident 1) was gone" and asked her to clean Resident 1 while he went to call Resident 1's wife. CNA stated, at that time, LN 1 then left the room. During an interview with the Administrator (ADMIN 1) on 7/28/14 at 7:40 P.M., ADMIN 1 stated, he expects the LNs to know the code status on all residents. ADMIN 1 further stated, LN 1 should have called for help and administered CPR. According to the facility's Policy and Procedure entitled, Designation of Resuscitation Status, dated June 1, 2009, ..."When a resident has designated his/her resuscitation status as "Full Code", the facility will provide the following: 1. activation of the Emergency Medical Service (EMS) system by calling 911. 2. Provision of CPR..." According to the American Heart Association web site, http://ocwfcd.org/american_heart_association_train.htm, "Effective bystander CPR, provided immediately after cardiac arrest, can double a victim's chance of survival." 3. On 7/24/14 at 2:15 P.M., a joint review of the facility's Policy and Procedure entitled, Designation of Resuscitation Status, was conducted with LN 6. Per the facility's policy "...The resident chart will be labeled as follows: Full Code Status- a sticker that reads Full Code will be affixed to the inside front of the chart. Do Not Resuscitate- a red dot will be affixed to the spine of the chart and a sticker that reads "DNR" will be affixed to the inside front of the chart... The facility will maintain a "Do Not Resuscitate" master list in the front of each MAR binder and the front of each TAR at each nurse's station..." LN 6 stated, she was not aware of this policy and confirmed she does not label resident's charts per policy. On 7/24/14 at 2:30 P.M., the chart cabinet at the nursing station was observed. Two random charts with red dots on the spine were reviewed. a. Resident 2's chart was observed to have a red dot on the spine (which indicated Resident 2 was a DNR), there was no code status indication sticker on the inside front of the chart, and Resident 2's POLST indicated that he was a full code. b. Resident 3's chart was observed to have a red dot on the spine (which indicated Resident 3 was a DNR), there was no code status indication sticker on the inside front of the chart, and Resident 3's POLST indicated that he was a full code. On 7/28/14 at 1:30 P.M., 19 resident charts were observed at the nursing station. All 19 resident charts were reviewed. a. 19 of 19 resident charts did not have any sticker indicating the resident's code status affixed to the inside of the chart, per the facility's policy. b. 10 of 19 resident's charts (4,5,6,7,8,9,10,11,12,) had no red dot on the spine (which, to an observer, indicated these residents were full code status), however, the resident's POLST's indicated DNR status. c. 1 of 19 (13), was labeled with a red dot on the spine (which indicated DNR status), however, the resident's POLST indicated full code status. On 7/24/14 at 2:32 P.M., LN 7 stated the red dot on the spine of Resident 2's chart indicated that Resident 2 needed "Medicare charting." LN 7 stated, if she found a resident unresponsive, she would check the POLST for the resident's code status. On 7/24/14 at 2:35 P.M., LN 3 stated the red dot on the spine of Resident 3's chart meant the Resident 3 was a "Medicare" resident. LN 3 stated, if she found a resident unresponsive, she would check the POLST in the resident's chart for code status. On 7/28/14 at 2:20 P.M., LN 2 stated the red dot on the spine means "Medicare" charting. LN 2 stated, she has been trained to call for help if she finds a resident unresponsive and then check the POLST in the resident's chart for code status. LN 2 further stated there was no other way to identify a resident's code status- only the POLST. On 7/28/14 at 7:30 P.M., ADMIN 1 stated the facility did not have a DNR master list in the front of each MAR or TAR. ADMIN 1 further stated, the facility is not following their policy on code status identification in properly labeling resident's charts with code status stickers and red dots. On 7/29/14 at 3:15 P.M., DON stated if staff found a resident unresponsive, they should call for help and someone should stay with the resident and another staff member should check the resident's POLST for the code status. DON stated there was no other way for staff to determine the code status of a resident other than the POLST in the resident's chart. The facility failed to notify and update the physician of Resident 1's abnormal vital signs and respiratory distress, and did not provide CPR when he became unresponsive, stopped breathing, and was without a pulse, even though his POLST indicated he wanted full resuscitative measures. The facility further failed to follow their policy and procedure for the identification of code status for other residents in the facility.The cumulative effects of 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. |
| 080000052 |
RANCHO VISTA |
080011648 |
B |
05-Aug-15 |
XHHI11 |
26845 |
Based on the comprehensive assessment of a resident, the facility must ensure that: 1. A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's condition demonstrates that they were unavoidable; and 2. A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. The facility failed to conduct skin and wound assessments according to the facility's policy, identify pressure ulcers (bed sores), develop interventions to prevent worsening pressure ulcers, and meet as a team to evaluate interventions for pressure ulcers for 3 of 10 sampled residents (8, 17, and 29). The facility failed to implement interventions to prevent pressure ulcers for residents at risk for developing pressure ulcers for 2 of 10 sampled residents (17 and 29). As a result, Residents 17 and Resident 29 experienced pain and decreased mobility when they developed pressure ulcers, and Resident 8 developed avoidable pressure ulcers which were worsened by a delay in treatment. 1. Resident 17 was admitted to the facility on 3/25/15, with diagnoses which included peripheral vascular disease (decreased circulation), and kidney disease. Resident 17 had a responsible party (RP) to make decisions on his behalf, according to the History and Physical, dated 3/26/15. Resident 17's record was reviewed on 4/17/15 at 8 A.M. According to Resident 17's Nurses' Admission Assessment, dated 3/25/15, Licensed Nurse (LN 1) documented Resident 17 had a Stage III pressure ulcer (full thickness tissue loss, fat may be visible but bone and tendon are not exposed) on his sacral/coccyx area (tailbone) and a Stage 1 pressure ulcer, presenting as non-blanchable redness, on both heels. According to the admission Pressure Ulcer Risk Screen, dated 3/25/15, Resident 17 was assessed as, "at risk" for developing pressure ulcers. Nursing did not obtain treatment orders from the physician for Resident 17's heels. On 3/26/15, the facility developed a nursing care plan entitled, Potential for Skin Problems. The plan of care included interventions for a low air loss mattress (therapeutic mattress used to prevent pressure ulcers), however; it did not include specific interventions for the non-blanchable redness (skin that does not lose redness when pressure is applied, can be the first sign of tissue destruction) on Resident 17's heels, such as floating the resident's heels or heel protecting boots. On 4/2/15, the facility developed a nursing care plan for the right and left heel with non-blanchable redness (8 days after the skin issue was identified). The plan of care included additional interventions including a pressure relieving device in wheelchair, however; it, again, did not include specific interventions for the non-blanchable redness on Resident 17's heels. On 4/6/15, Resident 17 was assessed by a podiatrist. According to the Podiatric Evaluation & Treatment form,"... Left heel posterior open area. Down to dermal layer (Stage II pressure ulcer)..." The Podiatrist recommended, "... referral to primary MD/ Vascular specialist for treatment orders and management left heel open area..." There was no documentation in the clinical record which indicated the LNs notified Resident 17's physician about the deteriorating pressure ulcer on the resident's heel following the podiatrist's visit. On 4/9/15, Licensed Nurse (LN 3) documented on the Ulcer Assessment flow sheet: "Left heel site A- unstageable pressure ulcer (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, or brown) or eschar (brown or black). Until slough or eschar is removed, to expose the base of the wound, the true depth and stage cannot be determined) 4 x 3 cm. (centimeters) 100% slough with moderate drainage Left heel site B- unstageable pressure ulcer 6.5 x 7.6 cm. Right heel site A- unstageable pressure ulcer 1 x 1.2 cm 75% eschar / 25% slough Right heels site B- unstageable pressure ulcer 5.2 x 8 cm." There were no treatment orders for the pressure ulcers on both of Resident 17's heels and no documentation the physician was notified of the worsening pressure ulcers on 4/9/15. Resident 17's plan of care was not revised to include new interventions to treat the worsening pressure ulcers. On 4/13/15, Resident 17's physician ordered treatments to the pressure ulcers on both heels (5 days after nursing assessed the wound had eschar and slough and was determined to be unstageable). There was no documentation in the record to show that nursing assessed and measured the pressure ulcers or revised the plan of care on 4/13/15. On 4/17/15 at 10:10 AM, Resident 17 was observed outside on the patio with his RP. Resident 17 was sitting in a wheel chair wearing brown slippers; his lower legs were swollen and wrapped in gauze. Resident 17 was observed wincing in pain, and said his heels hurt when he put pressure on them. The RP stated, "He has sores on the bottom of his feet." During an observation on 4/17/15 at 11 AM, Resident 17 was transferred from wheelchair to bed with the assistance of 2 therapy staff. The staff assisted Resident 17 to stand and pivot to a seated position on the edge of his bed. During the transfer, Resident 17 told the staff he was unable to move himself back in the bed because his, "foot hurt too bad to put pressure on it." Staff lifted the resident's legs on to the bed so that he was lying flat on his back. Resident 17 stated he was unable to assist staff to move him up in the bed by using his heels. Staff pulled the resident up in bed with a sheet. On 4/17/15 at 11:10 A.M., Resident 17 stated, his heels hurt when they were touched or moved. The Resident stated, "I can't stand up on it because it hurts." On 4/17/15 at 11:25 A.M., Licensed Nurse (LN 23) and the resident's primary physician (MD 1) were observed administering treatments to Resident 17's heels. LN 23 documented Resident 17's pressure ulcers had worsened from the previous assessment: "Left Heel: unstageable ulcer measuring 8.5 x 6.5 cm. 100% eschar; Right Heel: Stage III pressure ulcer (Full thickness tissue loss, fat may be visible but bone and tendon are not exposed) measuring 3.5 x 2.25 cm. 100 % slough with scant amount of drainage." On 4/17/15 at 12:30 P.M., Resident 17's record was reviewed with LN 23. According to the facility's Weekly Skin Audit Log, the LNs should have documented a Nursing Skin Audit which included a head to toe assessment of Resident 17' skin. In addition, the LNs should have completed an Ulcer Assessment which included measurements of Resident 17's pressure ulcers on: 3/26/15, 4/2/15, 4/9/15, and 4/16/15. LN 23 confirmed, Resident 17's clinical record contained no Nursing Skin Audits for 3/26/15, 4/9/15, or 4/16/15. In addition, Resident 17's clinical record contained no Ulcer Assessments for 3/26/15, 4/2/15, or 4/16/15. LN 23 stated she assessed Resident 17's pressure ulcers with MD 1 on 4/14/15. LN 23 stated she was surprised how much the ulcers had deteriorated. LN 23 stated, "It was bad." LN 23 was unable to find documentation of her wound assessment from 4/14/15, including measurements in the clinical record. LN 23 acknowledged, she should have notified the Registered Dietitian (RD), and updated the resident's plan of care. LN 23 stated she notified the Director of Nursing (DON) the pressure ulcers had worsened, but was unaware if the Interdisciplinary Team (IDT) met to discuss and plan interventions for the worsening pressure ulcers.On 4/21/15 at 10:50 A.M., the DON stated, the LNs should have reviewed the podiatrist's note on 4/6/15 and notified the primary physician of the podiatrist's recommendations. The DON also stated, the LNs should have assessed and measured Resident 17's pressure ulcers at least weekly and reported the changes to the physician. The DON confirmed, the IDT did not meet and discuss a plan to manage Resident 17's pressure ulcers. During a concurrent interview and record review on 4/21/15 at 11:50 A.M., LN 1 stated, she assessed Resident 17's skin on admission and did not notify the physician or the RP of the Stage I pressure ulcers to the resident's heels. LN 1 confirmed there were no treatment orders for Resident 17's heels on 3/25/15. LN 1 stated she assessed Resident 17's heel ulcers on 4/13/15, and noticed the right heel ulcer "was opened" (indicating the wound had further deteriorated to a Stage II pressure ulcer). LN 1 stated, she notified the physician and received new treatment orders (5 days after the right heel pressure ulcer was first identified on 4/9/15). LN 1 acknowledged, she did not document her assessment, did not measure the pressure ulcers on Resident 17's heels, and did not revise the plan of care. LN 1 stated, she was unaware of her responsibility to perform weekly measurements or skin assessments and she did not perform the weekly skin assessments or measure Resident 17's pressure ulcers. LN 1 further stated, she did not receive any training from the facility on wound or skin assessments. On 4/21/15 at 12:15 P.M., Resident 17's record was reviewed with Certified Nursing Assistant (CNA 3). According to the CNA Body Check sheet, the CNAs were responsible to document any issues noticed on residents' skin and report to the LN on each shower day. Resident 17's shower days were scheduled on: 4/2/15, 4/6/15, 4/9/15, 4/13/15, and 4/16/15. CNA 3 stated, she was responsible for Resident 17's showers the week of 4/2/15, and did not complete the body check. CNA 3 stated, the facility did not provide any education on skin checks, and she was unaware of her responsibility. During a telephone interview on 4/21/15 at 3:30 P.M., MD 1 stated she was unaware Resident 17's pressure ulcers had worsened until 4/14/15, and was unaware of the podiatrist's recommendations. MD 1 stated the LNs should have notified her. LN 3 was unavailable for interview during the survey. 2. Resident 29 was admitted to the facility on 2/11/15, for rehabilitation after removal of infected hardware to her left hip, according to the History and Physical dated 3/31/15.According to the same document, Resident 29 was re-admitted to the facility on 3/29/15, after a 10 day hospitalization with pneumonia, and she was able to make her needs known. On 4/14/15 at 2:30 P.M., Resident 29's room was observed from the hallway. Resident 29's call light was on and the resident could be heard yelling. On 4/14/15 at 3 P.M., Resident 29 was again heard yelling from her room. Resident 29 was observed lying in her bed and stated she was uncomfortable and did not feel well. During an interview on 4/15/15 at 9:45 A.M., Resident 29 was observed lying in her bed. Resident 29 stated, "I yelled out all day yesterday because my tailbone hurt so bad." The resident stated she was trying not to yell today but her, "tailbone hurt terribly." Resident 29 rated her pain as 10 out of 10 (0 meant no pain and 10 meant extreme pain) at that time. Resident 29 further stated, her mattress was hard and uncomfortable. Resident 29 stated she, "told a nurse a few days ago" her mattress was too hard, but she could not remember which nurse. During an interview on 4/15/15 at 11:55 A.M., Certified Nursing Assistant (CNA 6) stated, "She [Resident 29] used to get out of bed. Now she doesn't want to because it hurts her to sit in a chair." During an interview on 4/15/15 at 12:10 P.M., Licensed Nurse (LN 21) stated, Resident 29 complained of pain in her hip and bottom frequently, and sometimes shouted out. LN 21 stated, the pain medication was effective most times; however, sometimes Resident 29 called for pain medication an hour after it was given. LN 21 stated she had planned to notify the physician of Resident 29's increased pain. On 4/15/15 at 12:30 P.M., Resident 29's clinical record was reviewed. According to the Nurses' Admission Assessment, dated 3/29/15, Resident 29 had excoriated (scratched) skin on her coccyx (tailbone) and surrounding area. According to Resident 29's admission Pressure Ulcer Risk Screen, Resident 29 was "at risk" for developing pressure ulcers. According to the physician's orders dated 3/29/15, "...monitor for skin breakdown q [every] shift and prn [as needed]." On 3/30/15, LN 4 developed a nursing care plan entitled, Potential for Skin Problems, with a goal, "will have no skin breakdown for 90 days." Interventions included, "HDF [high density foam]" mattress and body check every week. On 4/07/15, Certified Nursing Assistant (CNA 21) documented on the Body Check form, Resident 29's buttocks were, "pink". The Body Check form was signed by the CNA and LN. There was no documentation in Resident 29's record the physician was notified of the pink area on the resident's buttocks and there were no treatments ordered. Nursing did not develop a plan of care to address the pink area. On 4/8/15 Licensed Nurse (LN 6) documented the following on Resident 29's Ulcer Assessment flow sheet: "Left buttock- Stage II pressure ulcer (shallow open ulcer with a pink wound bed) 0.4 x 0.4 cm Right Buttock- Stage II pressure ulcer 3.5 x 0.5 cm Coccyx- Stage I pressure ulcer (skin is unbroken, but shows discoloration) 7 x 6 cm" There was no plan of care developed to address Resident 29's newly developed Stage II pressure ulcers in the clinical record on 4/8/15. There was no documentation the Interdisciplinary Team (IDT) met to discuss Resident 29's pressure ulcers and no documentation Resident 29's Responsible Party (RP) (a person designated to make decisions on behalf of the resident) had been notified. On 4/14/15, LN 6 developed a nursing care plan for Resident 29's Stage II pressure ulcers. Interventions included, turning and repositioning the resident and treatments as ordered, however; there were no interventions for a pressure relieving mattress. During a concurrent observation and interview on 4/15/15 at 2:20 P.M., two CNAs were placing a white cotton mattress pad approximately 2 inches thick over the existing mattress on Resident 29's bed. Certified Nursing Assistant (CNA 2) stated, she was instructed to place the mattress pad over the existing mattress. CNA 2 stated, Resident 29 currently had a, "regular mattress." At that time, Licensed Nurse (LN 23) entered the room and stated, "She [Resident 29] complained her mattress was too hard, so I ordered her a mattress topper." LN 23 was unaware if Resident 29's current mattress was a pressure relieving mattress. On 4/15/15 at 5 P.M., Resident 29's clinical record was reviewed again. There was no documentation the physician was notified of Resident 29's increased pain by LN 21. During an interview on 4/16/15 at 9:50 A.M., the Registered Dietitian (RD 1) stated she was unaware Resident 29 had developed pressure ulcers, and the LNs should have notified her. RD 1 further stated, she was not involved in any IDT meetings to discuss a plan for Resident 29's pressure ulcers, and had not been consulted for recommendations. During an interview on 4/16/15 at 2:30 P.M., Licensed Nurse (LN 7), who was a certified wound nurse, stated she was not consulted or asked to administer treatments for Resident 29 and was unaware Resident 29 developed pressure ulcers. LN 7 stated the facility did not have a designated treatment nurse to assess, measure, and treat residents' skin issues. LN 7 stated she was not involved in skin or wound IDT meetings. Resident 29's mattress and mattress topper were observed with LN 7. LN 7 was unaware if the mattress was a pressure relieving mattress. LN 7 stated she had never seen that type of mattress topper before, and it was not a pressure relieving device. LN 7 further stated, Resident 7 was considered, "very high risk" for developing worsening pressure ulcers and needed a low air loss mattress (therapeutic mattress used to prevent pressure ulcers). During an interview on 4/16/15 at 3:05 P.M., the DON stated, the IDT did not collaborate as a team to discuss interventions to prevent the development and worsening of Resident 29's pressure ulcers. The DON further stated, the team did not discuss the possibility of a low air loss mattress for Resident 29. During an interview on 4/16/15 at 5 P.M., LN 7 stated she assessed and measured Resident 29's pressure ulcers, and the right buttocks ulcer had worsened to a Stage III pressure ulcer (Full thickness tissue loss, fat may be visible but bone and tendon are not exposed). LN 7 stated she called the physician, obtained new treatment orders, and an order for a low air loss mattress. LN 7 documented on the Ulcer Assessment flow sheet: "Right Buttocks Ulcer- Facility acquired Stage III 3 x 3.2 25% thin white slough 75% beefy red tissue." During an interview on 4/16/15 at 5:15 P.M., LN 6 stated she did not notify Resident 29's RP, and did not develop a plan of care to include interventions to prevent further breakdown of the pressure ulcers. LN 6 acknowledged, "I forgot to update the care plan so I did it last night" (7 days after the pressure ulcers were identified on 4/8/15). The nursing care plan developed by LN 6 did not include interventions for a pressure relieving mattress. LN 6 stated she was not aware if the IDT met to plan new interventions for Resident 29's pressure ulcers, and was unaware if there was a plan for a change in mattress for Resident 29. On 4/17/15 at 1:30 P.M., Resident 29's record was reviewed with LN 21. According to the facility's Weekly Skin Audit Log, the LNs should have documented a Nursing Skin Audit which included a head to toe assessment of Resident 29' skin. In addition, the LNs should have completed an Ulcer Assessment which included measurements of Resident 17's pressure ulcers on 4/2/15, 4/9/15, and 4/15/15. LN 21 confirmed the assessments and measurements were not done on 4/2/15 and 4/15/15. LN 21 stated she did not document a skin assessment or measure Resident 29's pressure ulcers on 4/15/15. LN 21 acknowledged, Resident 29's plan of care should have included a change in interventions when her pressure ulcers worsened, to include a low air loss mattress. During a joint interview and record review on 4/21/15 at 8:15 A.M., LN 4 confirmed she developed Resident 29's plan of care entitled, Potential for Skin Problems on 3/30/25. LN 4 confirmed she chose a High Density Foam (HDF) mattress as an intervention to prevent pressure ulcers. LN 4 was unaware if the HDF mattress was a pressure relieving device and was unaware if it was an appropriate intervention for Resident 29. During a concurrent observation and interview on 4/21/15 at 9:10 A.M., Resident 29 was lying in bed and remained on the same mattress and mattress topper as observed on 4/15/15. Resident 29 stated, she was expecting a new mattress but it had not been delivered. Resident 29 stated she did not want to get out of bed for therapy because her tailbone hurt when she sat in a chair. During a concurrent interview and record review on 4/21/15 at 9:20 A.M., Certified Nursing Assistant (CNA 21) stated she gave Resident 29 a bed bath on 4/7/15, and noticed a pink area on her buttocks. CNA 21 stated she notified Licensed Nurse (LN 22) of the pink area and documented, "pink buttocks" on the Body Check form. During an interview on 4/21/15 at 9:30 A.M., the Social Worker (SW 1) confirmed Resident 29's physician ordered a low air loss mattress on 4/16/15. SW 1 stated she was responsible for ordering the low air loss mattress from the vendor. SW 1 could not provide documentation that the low air loss mattress had been ordered from the vendor on 4/16/15. SW 1 stated she faxed the physician's order and requested the mattress from the vendor, "this morning" (5 days after it was ordered by the physician on 4/16/15). During an interview on 4/21/15 at 10:50 A.M., the DON stated, residents with risk factors such as Resident 29 should have a low air loss mattress to prevent skin breakdown. The DON also stated she expected the LNs to develop a plan of care with appropriate interventions and update the care plan as necessary. The DON stated she did not follow up on the status of Resident 29's low air loss mattress between the dates of 4/16/15 and 4/21/15. The DON stated, the LNs should have assessed Resident 29's pressure ulcers daily and notified the physician and RP of any changes. The DON also stated, the LNs should have reviewed the podiatrist's note on 4/6/15, notified the primary MD of the recommendations, and followed through with interventions. On 4/21/15 at 12:20 P.M., Resident 29's record was reviewed with Certified Nursing Assistant (CNA 8). According to the CNA Body Check form, the CNAs were responsible for documenting any issues noticed on the residents' skin and to report to the LN on each shower day, with or without shower. Resident 29's shower days were: 3/31/15, 4/3/15, 4/7/15, 4/10/15, 4/14/15, and 4/17/15. CNA 8 stated he was responsible for showering Resident 29 on 3/31/15, and 4/14/15. CNA 8 stated he did not do a body check on either date. CNA 8 stated he was unaware he was responsible to complete and document a body check, even when the resident refused the shower. CNA 8 confirmed there was no documentation Resident 29's body check was completed by a CNA on 3/31/15, 4/3/15, 4/10/15, 4/14/15, or 4/17/15. During a concurrent interview and record review on 4/21/15 at 2:30 P.M., Licensed nurse (LN 22) stated he assessed Resident 29 on 4/7/15 after CNA 21 notified him of the pink area on Resident 29's buttocks. LN 22 stated Resident 29 had an open area (Stage II pressure ulcer) on her right buttock. LN 22 acknowledged, he should have measured the pressure ulcer and notified the physician. LN 22 stated he did not update Resident 29's care plan, and should have included interventions such as, "notifying the RD and obtaining a new mattress" for Resident 29. During an interview on 4/21/15 at 1:05 P.M., the Administrator stated, "The staff did not order (Resident 29's) low air loss mattress until today." The Administrator confirmed Resident 29 had not received a low air loss mattress per the physician's order. 3. Resident 8 was originally admitted to the facility on 2/2/15, and then was re-admitted twice, on 2/8/15, and 3/8/15, according to the clinical record. Resident 8's admission diagnoses included rehabilitation and after care for trauma fracture lower leg, according to the facility's Face Sheet. Resident 8 did not have any pressure ulcers upon admission on 2/8/15, according to the Nurses' Admission Assessment. According to the nursing plan of care entitled, Potential for Skin Problems, dated 2/9/15, Resident 8's goal was to have "no skin breakdown x 90d [for 90 days]." The facility's plan was to "Observe and report redness, ... or open areas." Resident 8's skin check on 2/11/15, 2/16/15, 2/21/15, and 2/25/15, noted "pink" skin color on the coccyx area, as documented by CNAs and LNs, according to the Body Check record. Resident 8's skin check on 2/28/15, noted "open wound" on the coccyx area, as documented by the CNA and LN, according to the Body Check record. During a concurrent interview and record review on 4/16/15 at 11:30 A.M., the MDS Coordinator verified Resident 8 had one pressure ulcer in the sacral area (above the tailbone), according to the Nurses' Admission Assessment on 3/8/15. The pressure ulcer was described as "denuded [loss of some or all of the outer layer of the skin] coccyx 3 cm. x 4 cm. [Stage I]." The MDS Coordinator stated she could not find the nursing care plan for the coccyx pressure ulcer in Resident 8's clinical record. During an interview on 4/16/15 at 11:45 A.M., the Medical Record Director stated, "I don't see it [the care plan for pressure ulcer]." During a concurrent interview and record review on 4/17/15 at 11:20 A.M., LN 21 stated the care plan for pressure ulcer was not in the clinical record, and the physician was not notified about Resident 8's skin changes until 2/28/15.During an interview on 4/21/15 at 9:25 A.M., Certified Nursing Assistant (CNA 21) confirmed, she documented on the Body Check record on four occasions (2/11/15, 2/16/15, 2/21/15, and 2/25/15), Resident 8 had, "pink" skin on the coccyx area. CNA 21 stated, she verbally told the nurse Resident 8 had [a] "pink bottom," then handed the record to the LN to sign.During an interview on 4/21/15 at 8:45 A.M., the Administrator stated the other LN who signed the Body Check record (2/16/15, 2/21/15) was no longer an employee as of 3/31/15, and was unavailable for an interview. During an interview on 4/21/15 at 2:30 P.M., Licensed Nurse (LN 22) confirmed he received the Body Check record from CNA 21 and signed to acknowledge he had reviewed the information on 2/11/15 and 2/25/15. LN 22 stated, he should have assessed the resident, notified the physician, revised the care plan, and documented in the clinical record. LN 22 stated, "I didn't do it [on 2/11/15 and 2/25/15]." Clinical record review indicated, on 3/17/15, Resident 8 had two (2) documented pressure ulcers on the coccyx area, "coccyx site A" and, "coccyx site B," according to the Ulcer Assessment. Site A was described as Stage II, partial thickness, 2 cm x 2 cm; and Site B was described as Stage II, partial thickness, 1.4 cm x 1.3 cm. According to the facility's policy and procedure entitled, Pressure Ulcers, dated 1/1/09, "...2. Complete an entire body assessment... to identify the current skin condition. 3. Daily monitoring observations are completed by nursing assistants 4. Nurses Skin Audit is completed by licensed staff no less than weekly 5. If a pressure ulcer is present, an Ulcer Assessment is completed no less than weekly..." According to the facility's policy entitled, "Notification of Changes," dated 7/1/08, "... conditions that should be communicated to the physician: skin problems... any new orders obtained from other specialists... Document the following: a. the change that has occurred; b. who was notified; c. physician response..." According to the facility's policy entitled, "Care Planning- Interdisciplinary Team," undated, "... The Interdisciplinary Team shall develop a comprehensive care plan for each resident..." According to the facility's policy entitled, "Resident Assessment and Care Planning," undated, "... resident assessment information is used to establish, review, evaluate, and update the resident care plan ... if there is a change in condition..." According to the facility's policy titled, "Resident Assessment and Care Planning," undated, "The resident assessment information is used to establish, review, and evaluate, and update the resident care plan post admission...." Nursing failed to follow the policies and procedures to provide care and services for 3 of 10 sampled residents who developed pressure sores at the facility. These failures had a direct relationship to the health and safety of the residents. |
| 090001556 |
Reginas Court |
090012735 |
B |
16-Dec-16 |
6EKN11 |
8974 |
Federal Regulation, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), section 483.420 Client Protections, W 153, the facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures. Injuries of unknown source that give rise to a suspicion that they may be the result of abuse or neglect, should be reported immediately. Health and Safety Code - ?1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident [synonymous with client as used herein] of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. Based on observation, interview, and record review, the facility failed to ensure that injuries of unknown origin observed on one Client 1 were reported to the applicable state agency (California Department of Public Health, Licensing and Certification (Department) within 24 hours as required. The facility failed to ensure staff implemented facility policy and procedure related to abuse reporting when the direct care staff (DCS), licensed nurse (LN), and Qualified Intellectual Disabilities Professional (QIDP) failed to report an injury of unknown origin observed on Client 1 to the Department. The Department became aware of the injuries of unknown origin as the result of a report by a confidential complainant. These related failures resulted in a delay by the facility in reporting a possible abuse incident to the Department and other applicable authorities. This failure put Client 1 and other clients in the facility at risk for mental and physical stress, since the injuries of unknown origin could have resulted from staff-to-client or client-to-client abuse. This failure compromised Client 1's safety, when a complete investigation of the source of the injuries was not implemented since the injuries of unknown origin could have resulted from self-injurious behavior which required further attention by the behaviorist, psychologist, psychiatrist, or primary care physician. Findings: On 6/6/16 at 5:46 P.M., a confidential complaint was investigated regarding a report of multiple injuries of unknown origin, including bruises and scratches observed on Client 1. Client 1 was admitted to the facility on xxxxxxx with diagnoses that included an intellectual disability per the facility's Emergency Data Form. On 6/6/16 between 5:46 P.M. and 6:40 P.M., Client 1 was observed ambulating outside the facility in an enclosed yard. Client 1 was observed to require verbal prompts, and guidance, for all activities of daily living. Client 1 was observed to be ambulatory and able to follow the verbal prompts when calm. Client 1 was observed to have small yellow circular bruises on the right upper arm and a yellow bruise on the left upper chest area. Client 1 was observed to have a yellowish bruise on the left collarbone area. Client 1 was observed to not have any scratches or skin abrasions at the time. Client 1 was observed to slap and hit himself on the abdomen and chest three times during the observation. The DCS notes, dated 5/28/16 at 7:28 A.M., indicated that "Upon showering this morning staff noticed scratches and bruises on his right upper arm and shoulder as well his left bicep and across his chest. This staff did not witness the incident nor have any knowledge as to how they were inflicted. Nurse notified." The licensed nurse (LN) 1's notes, dated 5/28/16 at 1:49 P.M., indicated that "Nurse Assessment: 5/28/16 approximately 1:30 P.M., staff informed on-call nurse this morning during shower that Client 1 has scratches and bruises to his arms and shoulders. Bruises on front of both shoulder/chest. On left upper arm, 3 scratches that appear to be inflicted. On right upper arm front and back, bruises. On back right shoulder, imprints that are square shaped. On left shoulder blade, scratches. On right inner calf, bruise. Scratches appear to be recent, within the last day or two." On 6/6/16 at 6 P.M., a phone interview was conducted with the Qualified Intellectual Disabilities Professional (QIDP). The QIDP stated that the LN assessed Client 1's injuries after the direct care staff (RST) noticed them on the morning of 5/28/16. The QIDP stated that after T-logs (intra-facility communications similar to e-mails) back and forth with staff, and speaking to the San Diego Regional Center (SDRC), the QIDP sent a special incident report (SIR) to the SDRC on 6/6/16. The QIDP stated that his investigation of the injuries reported to the SDRC began on 6/1/16 (Monday) because the LNs T-Log were sent on 5/28/16 (Saturday). The QIDP stated he investigated whether the injuries had possibly been incurred at day program, in transport, or at the facility. The QIDP stated there was no evidence of abuse so the injuries remained classified as injuries of an unknown origin. The QIDP stated that the SIR was sent to the SDRC as a result of an inquiry by the case manager. The QIDP stated that the injuries were not reported to the CDPH because they were found to be from an unknown source and the client had programs for self- injurious behaviors. The QIDP acknowledged that the time for reporting within 24 hours had elapsed before he had reviewed the T-Logs form 5/28/16 on the following Monday, 5/30/16. The QIDP acknowledged that during the weekend DCS 1 and the LN had not sent the information further up the organizational hierarchy as should have been done. On 10/21/16 an interview was conducted with the Director of Program Services (DIR). The DIR stated that the injuries of unknown origin observed on Client 1 were investigated by the QIDP but not reported. The DIR stated that the injuries of unknown origin should have been reported according to regulatory reporting requirements to the Department and the SDRC and any other applicable agency. The DIR acknowledged that the reporting had not been correctly or timely accomplished by the facility in this situation. The facility policy and procedure, revised dated 2/2015, entitled, "Resident Protection: Recognizing and Reporting Abuse for Children and Dependent Adults" was reviewed. The abuse policy indicated that "All employees of [name of facility] are mandated reporters. The law requires that employees in long term care facilities, such as [name of facility], shall report under the following condition: The employee: observed has knowledge of an incident of abuse that reasonably appears to be abuse/neglect...Reasonably suspects - objectively "reasonable suspicion" based upon the facts...Under California law, failure to report known or suspected instances of abuse is a crime. There are strong penalties for those who fail to report...", "Possible Indicators of Physical Abuse: The following descriptions are not unnecessarily proof of abuse, but they may be clues that a problem exits. Signs that may indicate someone has been a victim of abuse may include: Unusual or recurring scratches, bruises, skin tears, welts...Injuries that are incompatible with explanations...", and "Reporting Procedure (As Determined By The Department of Justice) "Individual Duty" of Mandated Reporters. All employees as mandated reporters are required to report incidents of known or suspected abuse in two ways: By telephone immediately, or as soon as practically possible, to the local ombudsman, the local law enforcement agency (ICF-Intermediate Care Facility), to the local enforcement, local ombudsman and adult protective services...Resident Injury Report: 7. Department of Public Health Licensing (ICF) or Community Care Licensing (CCL) adults and children will be notified if injury involved abuse, or the injury requires serious medical attention, beyond first aid.." The facility failed to ensure that the facility policy regarding abuse reporting was implemented, when an injury of unknown origin was not reported to a supervisor within 24 hours of its occurrence and to the Department with a written report. As a result the injuries of unknown origin were not investigated by any outside agencies until the confidential complaint was received by the Department on 6/6/16, nine days after the injuries were first observed by the LN and DCS at the facility. The facility policy stated that all facility employees are mandated reporters, and by state laws are required to report alleged or suspected abuse within 24 hours to the Ombudsman, the Department, and law enforcement. Despite knowledge of an injury of unknown origin nothing was reported within the required time frame by facility staff. The above violations, either jointly, separately, or in any combination, had a direct or immediate relationship to health, safety, or security of Client 1 and other clients at the facility. |
| 010000082 |
Redwood Cove Healthcare Center |
110010573 |
B |
15-May-14 |
VPHK11 |
4095 |
72527(a)(9) Patients? Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse.The facility violated the regulations by failing to ensure that Resident 1 was free from abuse when Staff E put her leg on Resident 1 and was jumping around on the bed resulting in Resident 1 stated " it hurt " Resident 1's legs.Resident 1 was admitted to the facility on 2/8/12 with diagnoses including chronic low back pain. The Admission Minimum Data Set ( MDS- an assessment tool) dated 2/8/12, indicated that Resident 1 was alert and oriented and able to make his own medical decisions. During an interview on 6/26/12 at 9:30 a.m., Resident 1 stated there was one CNA (Certified Nurse Assistant) who usually worked on the evening shift who did not like him and was not nice to him. Resident 1 did not know her name but his description of her matched that of Staff E. Resident 1 stated that a couple days ago in the evening after he was put to bed, Staff E came into his room to answer his call light and started joking around with Resident 1. Staff E put her leg on Resident 1's legs and was jumping around. Resident 1 stated he yelled at her to get her leg off him because it hurt. During an interview on 6/27/12 at 1:55 p.m., Staff F stated on 6/23/12, around 10:30 p.m., Staff E passed her in the hall and was laughing. Staff E told Staff F she had done a lap dance on Resident 1. Staff F stated another CNA had also been told about the " lap dance" and had told Licensed Staff C. Staff F asked Staff G about it and they decided to check on Resident 1. Resident 1 told them that the CNA who had put him to bed was standing on his legs and that he yelled for her to get off.During an interview on 6/27/12 at 3 p.m., Licensed Staff C stated on 6/23/12 at 10 p.m., he was told by two CNAs that Staff E told them she had done a "lap dance" on Resident 1. Licensed Staff C stated he realized it was not a joke.During an interview on 7/2/12 at 1:30 p.m., Staff E stated on 6/23/12 she had put Resident 1 to bed around 8:30 p.m. and then she went to lunch. Staff E stated on returning from lunch she noted Resident 1's bed alarm sounding along with his call light ringing. When Staff E went into the room she noted that Resident 1 was very agitated and upset. Resident 1 wanted her to find another foot rest for his wheelchair as his was missing. Staff E stated she told him no and then started goofing around to cheer Resident 1 up. When Staff E was asked to describe what 'goofing around' was, she stated she started doing a little dance, but that Resident 1 just became more angry. Staff E was asked if she jumped up on his bed and she stated she had wanted to but didn't. She stated she did have her legs near his feet and Resident 1 told her to get away from his feet. Staff E stated she left the room and was going down the hall laughing and when one of her co-workers asked why she was laughing she said she had given Resident 1 a lap dance. The Facility's Policy and Procedure for the Abuse Prevention/Intervention Program, dated 2006, indicated "1. The facility's goal is to achieve and maintain an abuse free environment... 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..." The facility violated the regulations by failing to ensure that Resident 1 was free from abuse when Staff E put her leg on Resident 1 and was jumping around on the bed resulting in Resident 1 stating ?it hurt? Resident 1's legs. This violation had a direct relationship to the health, safety or security of the residents. |
| 010000082 |
Redwood Cove Healthcare Center |
110010719 |
A |
24-Oct-14 |
USMI11 |
19461 |
483.25 Provide Care/Services for Highest Well Being Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure Resident 1 received the necessary care and services to attain his highest practicable level of physical well-being when: 1 Facility Staff failed to provide comprehensive assessment of blood glucose, (sugar), levels for Resident 1 when 4 of 6 interviewed Licensed Staff did not recognize the significance of a " HI " result on the facility glucometer, 2. Facility Staff failed to develop a plan of care to address Resident 1's need to use an insulin pump to control blood sugar levels and the potential need for assistance with the pump, 3. Facility Staff failed to address Resident 1's need for immediate medical care for elevated blood sugar, when the attending physician was not notified of the delay in contacting a consulting physician to provide additional orders for elevated blood sugar. These failures resulted in a sustained delay in effective treatment of Resident 1's elevated blood sugar and contributed to the development of diabetic ketoacidosis that required hospitalization and had the potential for death.Diabetic Ketoacidosis, DKA, is a life threatening complication of diabetes that occurs when the body can not use sugar (glucose) for energy because there is no insulin or not enough insulin to metabolize the sugar. Fat is utilized for energy instead, when the fat breaks down, waste products called ketones build up in the blood. In high levels ketones are poisonous. The symptoms of DKA are nausea and vomiting in the presence of hyperglycemia (elevated blood sugar), and ketonuria (ketones in the urine), and can progress to coma and death. (American Diabetes Association; diabetes.org) The Physician Admit Note, dated 2/3/14, no time, indicated Resident 1 had been transferred to the skilled nursing facility from an acute care hospital, on 1/31/14 for intravenous antibiotics for a knee infection. The note indicated Resident 1 had insulin dependent diabetes managed with insulin administered via an insulin pump. Insulin dependent diabetes mellitus (IDDM), most often referred to as diabetes, is a chronic disorder characterized by inadequate production or utilization of insulin which results in excessive glucose, (sugar) in the blood and urine. A fasting blood sugar level for a person without diabetes is 60-110 mg/dL, (milligrams per deciliter-a measurement of amount per volume). (diabetes health center: webmd.com) The admission physician orders for Resident 1 dated 1/31/14, no time, directed the following: "Humalog (insulin lispro) solution; 100 unit/ml (milliliters); subcutaneous ( just under the surface of the skin) AC & HS-before meals and at bedtime Check Residents FSBS (Finger Stick Blood Sugar), before meals and at QHS, (bedtime). Tell Resident his blood sugar, and he will dose his own insulin via Humalog Insulin PUMP. Document the units he receives. Resident also needs to know how many Carbohydrates are in each meal prior to administration of Insulin." The medication package insert for Humalog (insulin lispro) noted it is a rapid acting insulin with an onset of action in 15 to 30 minutes, one half of the insulin is eliminated in approximately one hour, (half life elimination), (DailyMed.nlm.nih.gov/dailymed). A glucometer, a handheld device that measured blood sugar from a drop of blood obtained by fingerstick, was used to check Resident 1's blood sugar. Resident 1's insulin dependent diabetes was controlled by the administration of a medication called insulin. Resident 1 used an insulin pump, a computerized insulin delivery device, programmed to deliver a continuous small supply of rapid acting insulin 24 hours a day under the skin, into the patient's fatty tissue. In addition, the insulin pump could be programmed by entering the patient's current blood glucose level, to give bolus (additional) doses of insulin, such as before a meal, and/or a correction bolus when the blood sugar was too high. During an observation, on 2/5/14 at 1:35 p.m., Resident 1's family member displayed Resident 1's insulin pump. The black device, slightly larger than a cell phone, had manufacturer labeling that read, (insulin pump name), with the serial numbers of the pump. 1. Nursing Progress Notes dated 2/3/14 at 15:00 (3 p.m.), (recorded as a late entry on 2/4/14 at 13:56, [1:56 p.m.], and at 15:44, [3:44 p.m.]), indicated Resident 1 had an elevated blood sugar level in the early morning of 2/3/14, which was treated with a correction dose of insulin programmed by Resident 1, via the pump. The insulin pump subsequently ran out of insulin. The resident's wife brought a new cartridge to the facility and Resident 1 successfully changed the cartridge, providing new insulin. Nursing Progress Notes documented that Resident 1 began to vomit later that morning. At approximately 11:30 a.m., Resident 1's blood sugar was measured as HI on the facility glucometer. When Physician B was notified he directed staff to check Resident 1's urine ketone level, (When there is no insulin or not enough insulin to metabolize sugar fat is utilized for energy instead, when the fat breaks down, waste products called ketones build up in the blood. In high levels ketones are poisonous.) and to contact Physician D who was more familiar with the management Resident 1's diabetes. Further blood glucose levels checks at 1 p.m., and 1630 (4:30 p.m.), were documented as HI in the clinical record. As the day progressed Resident 1 became confused, began vomiting again, his blood glucose continued to read "HI". During an interview with Licensed Vocational Nurse C, (LVN C), on 2/7/14 at 11:25 a.m., LVN C stated Resident 1's ketone level was tested as 4+ (large), however no documentation of Resident 1's ketone level was found in the Nursing Progress Notes. Normal urine contains no ketones. Seen by Physician B in the early evening Resident 1 was transferred to an acute care hospital for treatment of elevated blood sugar. At the acute care hospital Resident 1's blood sugar was determined to be 827 mg/dL, and a urinalysis showed a ketone level of greater than 80 mg/dL in the urine. Resident 1 was diagnosed with diabetic ketoacidosis. The User Instruction Manual for the facility's glucometer, (name of glucometer), indicated the glucometer measured blood sugar levels to 599 mg/dL, at 600 mg/dL and above, the glucometer began to read only "HI". Pages 38 to 39 of the Manual, reviewed on 2/4/14, indicated the following: "High Blood Glucose Readings: If the blood glucose is above 600 mg/dL you will receive a "Hi". Repeat the test with a new test strip. If this message shows again, contact your health care professional immediately". During an interview, on 2/5/14 at 1:15 p.m., when asked what a HI reading on a glucometer meant to him, Resident 1 stated, "Maybe 450". During an interview, on 2/5/14 at 1:45 p.m., Resident 1's wife stated the facility staff only told her that the glucometer registered as HI. Resident 1's wife stated she thought HI was "Maybe 450 or so." During an interview, on 2/5/14 at 9:05 a.m., when asked how high the facility glucometer registered, the Director of Nursing stated she didn't know, she would have to check with the Licensed Nurses. During an interview, on 2/5/14 at 11:25 a.m., Registered Nurse F, (RN F), stated she thought HI on the facility glucometer was "anything over 550, but I'm really not sure."During interview, on 2/7/14 at 12:25 p.m., when asked what what a HI reading on the facility glucometer indicated, Licensed Vocational Nurse C, (LVN C), who provided direct care for Resident 1 on 2/3/14, stated he thought HI was maybe 500 mg/dL and up, but he had just found out that the facility glucometer actually gave a reading of HI if the blood sugar was 600 mg/dL or above. LVN C stated when he reported Resident 1's elevated blood sugar levels levels to Physician B and Physician D, he only told them the blood glucose was reading HI, and had not given them an actual number. During an interview, on 2/7/14 at 4 p.m., Licensed Vocational Nurse E, (LVN E), stated on 2/3/14 evening shift Resident 1 vomited and the glucometer blood sugar reading continued as HI. LVN E stated he knew a HI reading on the glucometer indicated a blood sugar of 500 (mg/dL) and above, he was unaware that it indicated a blood sugar of 600 (mg/dL) and above. During an interview, on 2/10/14 at 9:55 a.m. Physician B stated when facility staff notified him on 2/3/14 of Resident 1's elevated blood sugar levels, the staff did not give an actual number because, "The glucometer would go as high as 500, after that it would read high".Because each staff person, and Resident 1, had a different idea of what equaled a "HI" reading on the glucometer, the number entered into the pump as "HI" varied. Physician Progress Notes, dated 2/3/14 no time, indicated Resident 1's pump was programmed to give as a correction dose; 1 unit for every 30 points of blood sugar above the target blood sugar, which was 140 mg/dL according to a pump printout received on 2/10/14. Calculations with the above parameters indicated the following: Blood Sugar level- (minus) 140 mg/dL (target) =amount over target divided by correction dose of 30 units=amount of insulin required for correction dose, (to correct the blood sugar to target of 140 mg/dL). If the blood sugar level was 600 mg/dL, the correction dose would be 15.3 units, (600-140=460/30=15.3), however if the blood sugar was higher than 600 mg/dL, larger doses of insulin would be required to correct the blood sugar to the target of 140 mg/dL. Facility staff failed to recognize that due to the inability of the glucometer to accurately measure a blood sugar of 600 mg/dL or greater, the specific correction dose for a HI reading could not be calculated or given, since the actual blood sugar was unknown.2. Physician Progress Notes dated 2/3/14, no time, indicated that the management of Resident 1's insulin pump in the skilled nursing facility was "somewhat unclear". The Physician Progress Notes indicated that Resident 1 was confused and unable to manage the pump, and the "Staff is unclear how to manage pump either." Review of the plan of care for Resident 1 dated 1/31/14 indicated that eight potential or actual problems had been identified for Resident 1, with goals and approaches for each. Additional problems with goals and approaches were added on 2/2/14 and 2/3/14 The care plan did not address Resident 1's use of an insulin pump.Resident 1's clinical record record did not contain any indication that facility staff considered potential problems with Resident 1's use of an insulin pump or considered a process to manage the insulin pump if Resident 1 could not do so. 3. On 2/3/14 at 6:30 a.m. Resident 1's finger stick blood sugar was 420 mg/dL on the facility glucometer, and Resident 1 received 9.3 units of insulin via his insulin pump as documented on the Diabetes Management Flowsheet dated 2/3/14. During an interview, on 2/5/14 at 8:30 a.m., the Director of Nursing (DON) stated on 2/3/14 between 8:00 and 8:30 a.m., she assisted Resident 1 to change the cartridge in his insulin pump. The DON stated she had stayed to chat with Resident 1 when he started to vomit. During an interview, on 2/5/14 at 1:24 p.m., Resident 1's family member stated Resident 1 began to vomit about 9 a.m. on 2/3/14, and facility staff tried to notify Physician B but did not get an immediate response. Nursing Progress Notes dated 2/3/14 at 1500 (3 p.m.), recorded as a late entry on 2/4/14 at 13:56, (1:56 p.m.), documented that at 9 a.m., on 2/3/14, facility staff checked Resident 1's blood sugar after he vomited the first time. The note indicated that Resident 1's blood glucose was 396, and a check of the insulin pump had indicated the last dose of insulin Resident 1 received via the pump was 9.4 units at 9:39 a.m. During an interview, on 2/7/14 at 12:25 p.m., Licensed Vocational Nurse C (LVN C) stated he notified Physician B by fax and telephone when Resident 1 began to vomit.Documentation in an Event Note titled Emesis (vomiting), dated 2/3/14 at 1609, (4:09 p.m.), indicated Physician B responded at 10:45 a.m., approximately one hour and 45 minutes after Resident 1 started to vomit. During an interview, on 2/7/14 at 12:25 p.m., LVN C stated he informed Physician B that Resident 1 was vomiting and his blood sugar seemed to be getting higher.On 2/3/14 at 11:30 a.m., Resident 1's blood sugar was "HI" and he received 14 units of insulin via the insulin pump as documented on the Diabetes Management Flow sheet.During an interview, on 2/7/14 at 12:25 p.m., LVN C stated he called Physician B again to report the 11:30 a.m. "HI" blood sugar result. LVN C stated Physician B directed him to measure Resident 1's urine ketones, then to report the elevated blood sugar, and the urine ketone level to Physician D, who was more familiar with the management of Resident 1's diabetes. Physician B directed LVN C to call him back to tell him the ketone results and what Physician D said. During an interview, on 2/7/14 at 12:35 p.m., LVN C stated when he called Physician D's office the first time; the answering service told him Physician D was out between 12 and 2 p.m.On 2/3/14 at 13:00, (1 p.m.), Resident 1's blood sugar as "HI" and a dose of 14 units of insulin was given at 1 p.m. as a "Correction via pump", as documented on the Diabetes Management Flow sheet. Nursing Progress Notes, dated 2/3/14 at 16:17, (4:17 p.m.), recorded as a late Entry on 2/4/14 at 16:19 (4:19 p.m.), noted that Resident 1's wife assisted with "self-administrating insulin via pump." LVN C documented in the Nursing Progress notes dated 2/3/14 at 15:44 (3:44 p.m.), that he called Physician D at 1:13 p.m., at 2:03 p.m., and again at 2:12 p.m., when LVN C was able to talk to Physician D, 2 hours and 42 minutes after directed to do so by Physician B. During an interview, on 2/7/14 at 12:35 p.m., LVN C stated on 2/3/14 at 2:12 p.m., he reported to Physician D that Resident 1's glucometer blood sugar reading was "HI", he had been vomiting, and his ketone level was 4+. LVN C stated he received the following orders from Physician D: check a fingerstick blood sugar with the glucometer every two hours, and give a correction dose of insulin every four hours. Furthermore, if the vomiting continued, get a Basic Metabolic Panel, (a blood test that did not rely on a glucometer to measure serum blood sugar levels, and measured other blood values as well). During an interview, on 2/7/14 at 12:35 p.m., LVN C stated Resident 1's vomiting had stopped so he did not get the Basic Metabolic Panel drawn. LVN C stated he did not implement the new insulin orders, but passed them on to the evening shift nurse at 3:00 p.m., when LVN C went off shift, approximately 45 minutes after receiving the orders from Physician D. Resident 1's blood sugar was documented as HI at 16:17 ( 4:17 p.m.), on the Vital Signs record, two hours after the new orders were obtained from Physician D. During an interview, on 2/5/14 at 1:45 p.m., Resident 1's wife stated on 2/3/14, "At 2 p.m., things were awful. The facility was still trying to get a hold of Physician D, so I called Physician B myself." Resident 1's wife stated Physician B asked her for the parameters for Resident 1's insulin pump, which she provided. Resident 1's wife stated by 5 p.m., Resident 1 was still vomiting and was delirious. Resident 1's wife stated Physician B came to see Resident 1 between 5 and 6 p.m., about eight hours after Resident 1 began to vomit and five and a half hours after facility staff first noted a HI reading on the glucometer.Review of the Diabetes Management Flowsheet dated 2/3/14 indicated Resident 1 received a correction dose of 15 units of insulin at 1700, (5 p.m.). Review of a Transfer Note dated 2/3/14 at 1923 (7:23 p.m.), by Licensed Vocational Nurse E indicated that Resident 1 had vomited "all day, x 6 episodes" and his "blood sugars have been consistently above 500." The Transfer Note indicated Resident 1 had given himself 15 units of insulin twice in the last two hours with no effect. The Transfer Note indicated Physician B had seen Resident 1 "this afternoon" and upon further assessment decided to send Resident 1 to the acute care hospital. A Progress Note, written by Physician B, dated 2/3/14 no time, indicated Resident 1's ,"BG (blood glucose), now remains "High". Patient confused and unable to manage pump. Staff is unclear how to manage pump either. It seems prudent at this time and family would prefer it if pat(ient) was transferred to hosp(ital)." A note followed, that Resident 1 had been accepted in transfer to the acute care hospital.Acute care Emergency Department Notes dated 2/3/14 at 2145, (9:45 p.m.), indicated Resident 1 arrived with a decreased level of consciousness described as confused and unable to give a history, with nausea, vomiting, and increased heart and respiratory rates, 12 hours and 45 minutes after he first began vomiting and 10 hours and 15 minutes after the first reading of HI on the glucometer. Blood tests revealed Resident had a blood sugar level of 827, mg/dL. The urinalysis showed greater than 1000 mg/dL of glucose and a ketone level greater than 80 mg/dL in the urine. Normal urine contains no glucose or ketones. Resident 1 was diagnosed with diabetic ketoacidosis.Review of the 2010-2013 Merck Manual for Healthcare Professionals (Merck Sharp & Dohme Corp, Merck & Co, Whitehouse Station, NJ,USA) article titled Diabetic Ketoacidosis, indicated that the most urgent treatment goals for DKA are rapid fluid replacement and correction of elevated blood sugar by IV administration of insulin. "Treatment should occur in intensive care settings because clinical and laboratory assessments are initially needed every hour or every other hour with appropriate adjustments in treatment." The facility failed to ensure Resident 1 received the necessary care and services to attain his highest practicable level of physical well-being when Licensed Staff failed to provide comprehensive assessment of blood glucose, (sugar), levels for Resident 1 because Licensed Staff did not recognize the significance of a "HI" result on the facility glucometer. As a result Resident 1 did not receive insulin in sufficient quantity to correct his elevated blood glucose. When Resident 1 became confused and unable to manage his insulin pump due to his escalating symptoms of elevated blood sugar, facility staff did not have a plan of care to assist Resident 1 with the pump. Subsequent failure of the facility staff to notify the attending physician, Physician B, that a 2 hour and 40 minute delay occurred in reaching the consultant physician for additional orders to treat Resident 1's elevated blood sugar, urinary ketones and vomiting, extended the delay to obtain effective treatment of Resident 1's elevated blood sugar to 12 hours and 45 minutes from the time he began to vomit, and contributed to the development of diabetic ketoacidosis that required hospitalization and had the potential for death. 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. |
| 010000082 |
Redwood Cove Healthcare Center |
110010869 |
B |
02-Oct-14 |
99CQ11 |
7641 |
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. 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 violated the above regulations by:1. Failing to ensure Resident 1 was free from verbal abuse when Staff 1 shouted at Resident 1 and told Resident 1 to shut up. This behavior subjected Resident 1 to verbal abuse and had the potential to cause Resident 1 emotional distress and fear whereby a reasonable person would be humiliated.2. Failing to follow the abuse prevention policy when the facility did not prevent Staff 1 from having contact with Resident 1 during an investigation of allegations that Staff 1 yelled at Resident 1 causing the potential of subjecting Resident 1 to further abuse. On 5/22/14 the facility reported to the Department an incident that on 5/21/14 at 5:30 p.m., Staff 1 entered Resident 1's room and raised her voice to Resident 1 and told Resident 1 to shut up. During a review of the clinical record for Resident 1, the progress note dated 4/25/14 indicated Resident 1 had diagnoses which included cerebral vascular accident ( also known as stroke - an interruption of blood supply to the brain which can cause brain damage) with a left sided deficit, mainly wheelchair bound. Review of Resident 1's Minimum Data Set (MDS) (an assessment tool), dated 2/26/14 indicated this was an annual assessment. The facility documented Resident 1 exhibited verbal, behavioral symptoms directed towards others such as screaming at others, cursing at others. The resident's most recent Brief Interview Mental Score (BIMS) was 15/15 (reference: 15/15 indicated oriented with good short term recall). During an interview on 5/23/14 at 11:45 a.m., Resident 1 stated he did not remember someone yelling at him, nor did he remember Staff 1 yelling at him on 5/21/14. Review of Staff 1's written statement, Staff 1 wrote that on 5/21/14 at around 5 p.m., she could hear Resident 1 yelling "Nurse Nurse." She entered the room and said, "What the hell, [Resident 1], if your [sic] not on the floor bleeding or dying you don't need to yell like that, I mean seriously what the hell ..." Staff 1 further wrote that Licensed Staff 2 and Staff 3 entered the room and coached her that she was wrong and could not talk like that to the resident. Staff 1 then left the room to take a breath, came back in and apologized to Resident 1. During an interview with Staff 1, on 5/23/14 at 10:50 a.m., she stated it was late Wednesday [5/21/14], she was not feeling well and while she was in the restroom she heard yelling. She came out of the restroom and entered Resident 1's room as he was yelling. Staff 1 stated she raised her voice telling the resident he should not speak to the staff that way and for the resident to shut up. She stated Licensed Staff 2 and Staff 3 entered the room and stated Staff 1 should not speak that way to Resident 1. Staff 1 stated she apologized to Resident 1 and left the room. During an interview with Licensed Staff 2, on 5/23/14 at 2:20 p.m., she stated she was outside of the staff development office at the medication cart speaking with Staff 3. Staff 2 stated she could hear the resident yelling, "nurse nurse." She stated she then heard Staff 1 yelling at the resident. Licensed Staff 2 and Staff 3 went to Resident 1's room and observed Staff 1 at the foot of Resident 1's bed yelling at him. Licensed Staff 2 told Staff 1 it was not appropriate to yell at the resident and Staff 1 left the room. During an interview with Staff 3, on 5/23/14 at 11:30 a.m., she stated she was speaking with Licensed Staff 2 outside the staff development office and heard Resident 1 yelling, and then she heard someone yelling at Resident 1 loudly. She entered the room and observed Staff 1 standing at the end of Resident 1's bed yelling at him. She stated it was louder than someone raising their voice. It was like someone who might be on a baseball field yelling at their team member to catch a ball. She stated that she and Licensed Staff 2 told Staff 1 this was not right and Staff 1 left the room. During a review of the facility's investigative report, dated 5/23/14, indicated that Administrator 1 was notified by Staff 3 via telephone on 5/21/14 at 5:30 p.m. Staff 3 reported she had witnessed Staff 1 inappropriately yelling at Resident 1. Administrator 1 contacted Staff 1 on 5/21/14 at 6:03 p.m., to discuss the allegations of inappropriate conduct between Staff 1 and Resident 1. Staff 1 admitted her "attitude was inappropriate with him." The investigative report documented that Administrator 1 contacted Administrative Staff 2 on 5/22/14 at 10:00 a.m., and requested Administrative Staff 2 to interview Resident 1 and employees who may have witnessed the incident and that Staff 1 was suspended that day. The facility had substantiated Staff 1's inappropriate attitude and unprofessional conduct towards Resident 1. Staff 1 documented that she returned to work on 5/22/14 and reported to the Director of Nursing (DON) the previous day's event.Staff 1 wrote she answered Resident 1's call light several times on 5/22/14, each time talking calmly and respectively. At 1:30 p.m., she was called into the DON's office and was placed on suspension pending the investigation. During an interview on 8/20/14 at 11:30 a.m., Administrative Staff 2 stated she was not aware Staff 1 had answered the nurse call bell and assisted Resident 1 on 5/22/14. She could not recall the time Staff 1 reported for duty on 5/22/14. She stated that at the standup daily meeting held on 5/22/14 at 9:00 a.m. - 9:30 a.m., she requested Staff 1 not to assist Resident 1. The facility policy and procedure titled, "Abuse Prevention Program" revised November 2010 indicated, "Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion." The policy defines "Verbal abuse" as any use of oral, written or gestured language that willfully 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. During abuse investigations, residents will be protected from harm by the following measures: Employees accused of participating in the alleged abuse will be immediately reassigned to duties that do not involve resident contact or will be suspended until the findings of the investigation have been reviewed by the Administrator. Therefore, the facility violated the regulations by: 1. Failing to ensure Resident 1 was free from verbal abuse when Staff 1 shouted at Resident 1 and told Resident 1 to shut up. This behavior subjected Resident 1 to verbal abuse and had the potential to cause Resident 1 emotional distress and fear whereby a reasonable person would be humiliated.2. Failing to follow the abuse prevention policy when the facility did not prevent Staff 1 from having contact with Resident 1 during an investigation of allegations that Staff 1 yelled at Resident 1 causing the potential of subjecting Resident 1 to further abuse. The violation of the regulations had a direct relationship to the health, safety or security of patients. |
| 010000959 |
RAFAEL CONVALESCENT HOSPITAL |
110010871 |
B |
25-Jul-14 |
0OTT11 |
2174 |
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. Based on observation, resident and staff interviews, and medical record and document reviews, the facility failed to protect Resident 1 from verbal and physical abuse when DCS A (direct care staff) yelled at the resident and slapped her leg while providing care. These actions had the potential to negatively impact the resident's psychosocial well-being.Finding: Resident 1 was a 89 old female, who was admitted to the facility on 8/20/12 with multiple medical diagnoses which included Alzheimer's, dementia, and left heart failure.A written statement by DCS B, dated and signed on 1/10/14, indicated DCS B witnessed the incident: "I saw [DCS A] try to take [Resident 1's] shirt off in a rough manner, then [DCS A] said to [Resident 1] if you say anything else I am going to kill you ...and [DCS A] took her right hand with a glove on and grabbed [Resident 1's] face roughly then [DCS A] got down on her knees to clean [Resident 1's] legs and she hit [Resident 1] once on the left leg and twice on the second leg ..." On 1/14/14 at 1:15 p.m., Resident 1 was observed in bed, in her room. The resident was forgetful, being unable to remember what the day or month was, when asked. The resident, when asked, did not remember the incident. A review of the facility's investigation, dated 1/13/14, indicated Administrative Staff C interviewed DCS A. The investigation report indicated DCS A admitted the resident was rough and hard to deal with and also stated to Administrative Staff C "that she hit the resident on the back only once" to get her attention.A review of the facility policy on abuse prevention, not dated, indicated there was a zero tolerance for abuse of any nature. The resident has the right to be free from abuse. The violation of this regulation had a direct or immediate relationship to the health, safety, or security of the resident. |
| 010000082 |
Redwood Cove Healthcare Center |
110011033 |
A |
23-Dec-14 |
P8QR11 |
7115 |
?483.25(h) Free of Accidents 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 Resident 2 with adequate supervision to prevent accidents when Resident 2, who was identified by the facility at risk for falls and elopement, was left unsupervised on an outside patio. Resident 2 lost control of her wheelchair, rolled down a hill and fell out of her wheelchair. This placed Resident 2 at risk of rolling into a parked or moving vehicle, leading to serious injury or death. Record review on 7/9/14 indicated Resident 2 was admitted to the facility on 2/15/13 with diagnoses including Alzheimer's disease (a progressive brain disease affecting thinking and judgment) and stroke. The Resident Admission Record indicated Resident 2 was not "responsible for self," and listed a responsible party. Resident 2's Minimum Data Set (MDS), a resident assessment tool, dated 5/19/14, reflected a Brief Inventory of Mental Status score of 6, indicating severe cognitive impairment. The MDS reflected diagnoses which included Alzheimer's disease, stroke, and hemiplegia or hemiparesis (paralysis or weakness on one side of the body.) Resident 2's care plan included an entry dated 5/1/14 for the problem "Resident is at risk for injury [related to] elopement episodes and wandering behaviors secondary to dementia and cognitive deficits." Interventions included: 1) Wanderguard on resident for safety and to alert staff of resident's attempts to elope, 2) RP (responsible party) informed of elopement as well as placement of wanderguard alarm on resident, 3) Encourage resident to be in a supervised area when out of bed, and 4) Offer resident and assist as needed in joining activities of choice.A document titled Observation Report: Elopement Risk, initiated 5/19/14 and completed 6/2/14, identified Resident 2 as being intermittently confused, with slow comprehension, requiring assistance with ambulation, independent in her wheelchair, and exhibiting "wandering with no rational purpose and attempting to open doors." Conditions identified included stroke, dementia, and depression. Interventions included door alarm band applied (Wanderguard), identification band on resident, personal movement device (tab alarm), and photograph placed in elopement binder. During an interview on 7/9/14 at 11:45 a.m., Management Staff C stated Resident 2 wanted to go outside in her wheelchair on the morning of 6/19/14. Management Staff C stated he opened the door for Resident 2 so she could sit on the patio in front of the building. Management Staff C stated he believed it was okay because another staff member (Therapy Staff D) and another resident were also going to the patio. Management Staff C stated Resident 2 had a Wanderguard alarm (a wrist/ankle band which triggers an alarm when passing through doors equipped with the security system), and it made an audible noise as Resident 2 exited the building.Management Staff C stated approximately five minutes after Resident 2 exited the building, Therapy Staff D alerted Management Staff C and Management Staff E that Resident 2 had fallen. Management Staff C found Resident 2 face down in the lawn between the facility footpath and a public sidewalk. Resident 2's wheelchair was behind her, still upright.During an interview on 7/9/14 at 1:45 p.m., Resident 2 was asked if she remembered falling in the grass recently. Resident 2 stated she "tried to walk by myself but it didn't work." Resident 2 stated she was able to unlatch the patio gate by herself. During an interview on 7/24/14 at 1:15 p.m., Therapy Staff D stated she was pushing a resident in a wheelchair and had pulled her computer station toward the front door of the facility on 6/19/14 when she observed Management Staff C hold the door open for Resident 2 and state, "Come on out. We'll get that." Therapy Staff D stated she assumed Management Staff C was referring to the alarm which sounded when Resident 2 passed through the door. Therapy Staff D worked with the other resident in the northwest corner of the patio when she heard Resident 2 yelling. Therapy Staff D stated she stood up, looked around a stone pillar, and saw Resident 2 roll down the hill beyond the south gate of the patio. She was unable to reach her before Resident 2 fell out of her wheelchair onto the grass. Therapy Staff D stated nobody asked her to supervise Resident 2 while on the patio. Therapy Staff D stated she "was focused 100%" on the resident to whom she was providing therapy. Therapy Staff D stated her personal procedure when leaving a resident is to ask another staff member to supervise the resident until her return. Therapy Staff D stated the stone pillars on the patio prevented her from seeing Resident 2's movement toward the gate.During an interview on 7/24/14 at 3:45 p.m., Unlicensed Staff I was asked what staff members did when they heard a Wanderguard alarm. Unlicensed Staff I stated "everyone goes to check and make sure someone is with the resident." When asked if Resident 2 had any safety awareness, Unlicensed Staff I stated, "Not really." Unlicensed Staff I stated she did not think Resident 2 was able to lock the brakes on her wheelchair, and she often tried to stand up from her wheelchair. During observation on 7/9/14 at 12:05 p.m., the patio from which Resident 2 exited was noted to front a north/south oriented street with one vehicle lane, one bicycle lane, and parallel curb parking in each direction. The posted speed limit is 30 miles per hour. Twenty-five vehicles drove past the facility in a timed two-minute period. The patio is enclosed on three sides by a wooden fence approximately 2 1/2 feet high. The north and south ends of the patio have gates with unlocked latches. The gates open inward. The gate at the south end opens onto a curved, paved path to the sidewalk, with sloping lawn to the left of the path. Resident 2 exited the patio through the south gate, began rolling in her wheelchair down the path, and fell into the lawn. The gate at the north end opens to a similar path to the sidewalk, as well as a paved walkway to the facility driveway from which cars access a large parking lot in the back of the building.The patio has two stone pillars extending from the ground to the building overhang, obscuring visualization of the full patio from many positions.The facility failed to provide Resident 2 with adequate supervision to prevent accidents when Resident 2, who was identified by the facility at risk for falls and elopement, was left unsupervised on an outside patio. Resident 2 lost control of her wheelchair, rolled down a hill and fell out of her wheelchair. This placed Resident 2 at risk of rolling into a parked or moving vehicle, leading to serious injury or death. The violation 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. |
| 110001248 |
Rocky Point Care Center |
110011542 |
B |
11-Aug-15 |
RNNF11 |
3603 |
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 ensure Resident 1's right to be free from verbal abuse when a certified nursing assistant (Staff A) used derogatory language toward Resident 1. This subjected Resident 1 to verbal abuse and psychosocial distress. Resident 1 stated the incident made him feel, "not very good." A facility incident report, dated 8/17/14, indicated certified Staff A made derogatory remarks to Resident 1 on 8/16/14. A follow up Incident / Abuse / Neglect Report, dated 8/21/14, documented Staff A admitted to calling Resident 1 an "A 'Hole" and the staff was terminated. During an interview on 9/2/14 at 2:30 p.m., the Director of Nurses (DON), Staff C, stated she conducted an investigation and substantiated the allegation. Staff C stated she interviewed witnesses who reported Resident 1 told them Staff A had called him an, "ugly a-hole".Staff C's written notes of the investigation, dated 8/18/14, documented on the evening of 8/16/14, Resident 1 asked Licensed Staff D if he [Resident 1] was ugly. Resident 1 then stated Staff A had called him an asshole earlier that day.Staff C's investigation notes documented certified Staff B reported to licensed Staff F that on 8/16/14, Resident 1 reported to Staff B that Staff A had called him an asshole and told him he was ugly. Resident 1 asked Staff B if he (Resident 1) was ugly. The notes indicated Staff A must have overheard the conversation because Staff B reported Staff A called out from another room, "Well if you hadn't of treated me so badly, I wouldn't have called you an asshole."The facility investigation notes documented Staff A was interviewed by Staff C (DON) on 8/18/14. Staff C's investigation notes documented during the interview, Staff A stated, "Yes I called him an ugly asshole ... after he called me a bitch ..." The notes documented Staff A stated Resident 1, " ... called me a bitch; so I told him, I'm putting you back in bed after this - I don't have to put up with this shit.' So he called me a bitch again and a few other names - so yeah ... I called him an ugly asshole. It just slipped outta my mouth." When asked about calling out from another room, Staff A stated, "... I was tired already of hearing him tell others about what happened so I hollered over 'yeah, well if you hadn't of treated me so mean, I wouldn't have called you an asshole' ..." Resident 1's Care Plan History, dated 7-21-14 to 8-21-14, documented Resident 1's diagnoses included a history of stroke and depression and the resident was his own responsible party. The resident's Minimum Data Set Assessment (an assessment tool), dated 2/16/14, documented the resident had some memory problems.During an interview on 9/1/14 at 3:30 p.m., Resident 1 stated Staff A told him he was ugly. When inquiry was made as to how that made him feel, Resident 1 stated, "not very good. I feel OK now. I asked others if I'm ugly and they said no." The facility failed to ensure Resident 1's right to be free from verbal abuse when a certified nursing assistant (Staff A) used derogatory language toward Resident 1. This subjected Resident 1 to verbal abuse and psychosocial distress.This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to residents. |
| 010000082 |
Redwood Cove Healthcare Center |
110012375 |
A |
29-Jul-16 |
1BC911 |
12680 |
483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure the necessary care and services were provided to attain the highest practicable physical well-being for one resident (Resident 1), identified by the facility as at risk for dehydration, when: Recommendations made by the registered dietician (R.D.) for increased fluids were not implemented; and when licensed staff (Licensed Nurse B) failed to follow the facility's policy and procedure to notify the physician of Resident 1's significant change in condition. Resident 1 had a low intake of fluids, three episodes of liquid diarrhea, had increased weakness, paleness, confusion and low blood pressure. Resident 1 was transferred to the acute care hospital and diagnosed with dehydration and acute (sudden, severe onset) kidney failure. Review of the admission nurse's notes for Resident 1, dated 2/20/16, documented Resident 1 had diagnoses that included progressive weakness, morbid obesity, urinary tract infection, chronic low back pain, depression and hypertension (high blood pressure). Resident 1 was described as "alert and oriented x3" (oriented to person, place, time) and "capable of giving consent...and was able to sign all paperwork without difficulty." Review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 2/27/16, Section B, Hearing, Speech, and Vision, indicated Resident 1 had adequate vision and hearing (had a hearing aid), and clear speech. Resident 1 was able to make self understood and understood others. Section C, Cognitive Patterns, indicated a Brief Interview for Mental Status (BIMS) score of 14 (scores of 13-15 denoted intact cognition/mental processes.) Section G, Functional Status, indicated Resident 1 required extensive assistance of two or more persons for positioning in bed, transfers from bed and/or wheelchair, dressing and personal hygiene. Resident 1 was dependent upon one person to assist with eating and drinking. Review of a progress note for Resident 1, dated 3/23/16, Dietary Staff E noted Resident 1 had a decrease in fluid and meal intake and Resident 1 needed assistance with eating and drinking due to muscle weakness. Review of Resident 1's Care Plan for "Nutritional Status," dated 3/28/16, indicated Resident 1 was at risk for dehydration. The goal was for Resident 1 to "have >75% po (oral) intake of food and fluids served." Approaches (interventions) to reach the goal included RNA (restorative nurses aide) dining and assistance with meals. Concurrent review of the facility's Dehydration Risk Assessment, also dated 3/28/16, indicated Resident 1's risk factors contributing to the potential for dehydration included the need for physical assistance with fluid intake/eating, history of urinary tract infection (UTI), depression, was taking a diuretic (medication that promotes the production of urine) and had a history of constipation and laxative use. During the Interdisciplinary Team meeting (IDT- a meeting of facility department heads and nursing staff to discuss the status of the residents) on 3/29/16, the nursing department notes indicated Resident 1's Dehydration Risk assessment score was "6" (at risk for dehydration). Review of the R.D.'s assessment / progress note, dated 4/4/16, indicated Resident 1's average intake of fluids was 900-1000 milliliters (mL) per day - about 3-1/2 to 4 cups. Using a formula of 30-35 mL/kg (milliliters per kilogram of weight) the R.D. calculated Resident 1's daily fluid needs was 2700-3150 mL per day, or approximately 11-13 cups of fluid per day. The R.D.'s recommended intervention was to have licensed nurses offer an additional 240 mL three time a day to Resident 1, "to support hydration status." During an interview, on 5/13/16 at 12:10 p.m., when asked if Resident 1's Care Plan was updated to include the addition of 240 mL of fluids three times a day recommended on 4/4/16, the R.D. stated, "I believe I communicated with [The Director of Nursing (DON)] regarding this." When asked if she documented the communication, the R.D. stated, "If I fax the [physician] an order request, then it would get documented in the orders." Review of the physicians' orders dated between 4/4/16 and 4/7/15 did not contain any new orders for increasing Resident 1's fluid intake. Additional record review indicated the R.D.'s progress note, with the recommendation (for additional 240 ml of fluids three times a day), was sent, date unknown, to Resident 1's physician's office, however, the physician who approved the recommendation did not date the order and it was not signed off (noted) by the facility until 4/8/16, the day after Resident 1 was transferred to the hospital. Review of Resident 1's "Vitals Report," (a flow sheet that documented intake of fluids, meals, supplements; number of bowel movements [BM's] and urination) from 4/1/16 to 4/7/16, indicated Resident 1 averaged a fluid intake of 1006 mL per day. In addition, the Vitals Report indicated the following: 4/6/16 at 12:26 p.m., Resident 1 had a medium amount of liquid BM. 4/6/16 at 19:32 (7:32 p.m.) Resident 1 had a large amount of liquid BM. 4/6/16 at 22:27 (10:27 p.m.) Resident 1 had another large amount of liquid BM. There was no documentation Resident 1's physician was notified of her diarrhea. Review of Mayo Foundation for Medical Education and Research(MayoClinic.org/Dehydration 1998-2016) when a person becomes dehydrated, the body loses more water than it takes in. Even mild dehydration can cause weakness, dizziness and fatigue. Fever, vomiting, severe diarrhea, overuse of diuretics, decreased fluid intake and strenuous exercise can all lead to dehydration. Complications can include kidney failure and hypovolemic (low blood and fluid volume in the body)shock, a life-threatening complication of dehydration, which occurs when low blood volume causes a sudden drop in blood pressure and a reduction in the amount of oxygen reaching your tissues. If untreated, severe hypovolemic shock can cause death within a few minutes or hours. A Physical Therapy note, dated 4/6/16 at 4:11 p.m. documented Resident 1 reported feeling unwell and reported diarrhea throughout the day. Review of Licensed Nurse B's progress note, dated 4/6/16 at 10:21 p.m., indicated Resident 1 was "weak, speech difficult to understand...color pale...confused ... blood pressure 94/58." (Current guidelines identify normal blood pressure as 120/80.) Licensed Nurse B documented she, "Suggested [Resident 1] go to Hospital for evaluation, but resident adamantly refused x3 (three times)." On 4/7/16, at 7 a.m., Licensed Nurse B documented Resident 1 continued to be "very weak, disoriented through the night [night shift] when awakened...Continues very pale." There was no documentation Resident 1's physician was informed of her decline, change in condition and refusal to go to the hospital. A progress note for Resident 1, dated 4/7/16 at 12:22 p.m., the DON documented at 9:15 a.m. staff had requested she see Resident 1, patient's blood pressure was low 71/46, had dysarthria (difficult or unclear expression of speech), left arm was flaccid (weak or limp)patient had trouble following simple commands, was unable to stick out tongue. Covering physician was contacted at 9:27 a.m. and received order to transfer resident to the emergency department. Resident was transferred to the emergency department at 9:50 a.m. A physical therapy aide note, dated 4/7/16 at 12:51 p.m. documented Resident 1 had continued to look very pale, had difficulty forming words, was very disoriented and had increased difficulty with her right hand grip. Reported to nursing and resident was taken to the hospital within the hour. During an interview, on 5/5/16 at 3:20 p.m., after reading Licensed Nurse B's progress note dated 4/6/16 (above) the DON was asked if the resident's physician should have been called for the change of condition Resident 1 was experiencing. The DON stated, "Yes." During a telephone interview, on 5/4/16 at 9:40 a.m., Family Member D stated she saw Resident 1 [on 4/5/16], two days prior to being sent to the hospital, and "she was fine." On 4/7/16, Family Member D stated she received a call from the facility with a report that Resident 1 might be having a stroke and the facility was transferring Resident 1 to the hospital. At the hospital, Family Member D described Resident 1 as being "out of it." Family Member D stated the emergency room physician reported "[Resident 1] presented (came into the hospital) with severe dehydration and renal failure." The decision was made to provide Resident 1 with intravenous (IV) fluids and Family Member D stated Resident 1, "Started getting more lucid and started getting better." Review of the hospital's Emergency Department (ER) Report, dated 4/7/16, indicated Resident 1 arrived at the hospital, "...at times...able to answer questions with some difficulty speaking and dysarthria ...then a short time later...would be...nearly totally obtunded (decreased level of consciousness/hard to arouse) unable to answer questions or obey simple commands." This was further assessed, by the ER physician as "altered mental status." On exam, Resident 1's mouth was dry and the tongue was furrowed, and her blood pressure was low at 98/61 and she had had diarrhea again. Concurrent review of laboratory data collected on 4/7/16 indicated Resident 1's renal function was compromised with BUN (blood urea nitrogen) and creatinine (the primary tests used to check how well the kidneys are able to filter waste products from the blood) levels of 63 and 2.92, respectively. Normal BUN levels are generally between 7-20 and creatinine levels are between 0.5-1.5. According to The National Kidney Foundation, when kidney function slows down, the creatinine...and BUN levels rise. Review of Resident 1's hospital Discharge Summary, dated 4/12/16, indicated Resident 1 was "quite dehydrated", her initial presentation of altered mental status was, "...likely related to dehydration," and "After gentle fluid resuscitation, [Resident 1's] mentation (mental activity) cleared." Resident 1 was diagnosed with acute (sudden onset) renal failure and, "...BUN and creatinine [blood tests for kidney function] normalized with...IV hydration." During a telephone interview, on 5/20/16 at 8 a.m., when asked if the physician was called or alerted to Resident 1's episodes of diarrhea, the DON stated no. During an interview on 5/20/16 at 8 a.m., Licensed Nurse B stated Resident 1 had complained of feeling sick during the night of 4/6/15 through 4/7/16 (night shift) however, Resident 1 was not specific to what symptoms she was having. Licensed Nurse B acknowledged Resident 1 was "in a decline" and stated she "observed her closely." When asked if the physician was called and informed of Resident 1's decline in health, and her refusal to go to the hospital, Licensed Nurse B stated, "If it's not documented, then, no." Review of the facility's Policy and Procedure titled, "Change in a Resident's Condition or Status," revised April 2007, the Policy Interpretation and Implementation section, #1, indicated "The Nurse...will notify the resident's Attending Physician or On-Call Physician when there has been: ...A significant change in the resident's physical/emotional/mental condition; Refusal of treatment; A need to transfer the resident to a hospital..." #2, indicated, "A 'significant change' of condition is a decline...in the resident's status that: ...Will not normally resolve itself without intervention..." Therefore, the facility failed to ensure the necessary care and services were provided to attain the highest practicable physical well-being for Resident 1, identified by the facility as at risk for dehydration, when: Recommendations made by the registered dietician (R.D.) for increased fluids were not implemented; and when licensed staff (Licensed Nurse B) failed to follow the facility's policy and procedure to notify the physician of Resident 1's significant change in condition. Resident 1 had a low intake of fluids, three episodes of liquid diarrhea, had increased weakness, paleness, confusion and low blood pressure. Resident 1 was transferred to the acute care hospital and diagnosed with dehydration and acute (sudden, severe onset) kidney failure. This failure presented either imminent danger that serious harm would result or a substantial probability that serious harm or death would result. |
| 110001248 |
Rocky Point Care Center |
110012513 |
A |
15-Sep-16 |
OUQ811 |
22175 |
F314 ?483.25(c) Treatment/Svcs to Prevent/Heal Pressure Sores Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility failed to provide Resident 10, with necessary treatment to prevent the development and progression of a pressure ulcer. The facility failed to ensure a care plan was developed upon admission for care of the resident's skin under her leg immobilizer brace (splint to prevent movement of the leg); failed to ensure ongoing skin and wound assessments after wound dressing changes in order to determine effectiveness of treatment and in accordance with standards of practice; failed to develop policies and procedures for ongoing wound assessments and prevention of pressure ulcers for residents with a leg brace/immobilizer; failed to ensure a physician assessed and evaluated the resident's wound under her brace before the wound became necrotic (contains dead tissue, which usually results from an inadequate local blood supply) and deteriorated to an unstageable wound with necrotic tissue which required surgical debridement (surgical removal of necrotic tissue in order to promote healing and reduce infection). These failures resulted in Resident 10 developing a pressure ulcer under the leg immobilizer brace which progressed to a Stage 4 pressure ulcer (Full thickness skin loss exposing muscle or bone). Review of the facility's electronic "Observation Report" dated 10/12/15 indicated Pressure sore classifications included: DTI- (DeepTissue Injury) a pressure related injury to subcutaneous (beneath the skin) under intact skin. Stage 1 -Non blanchable (remains red when pressed) erythema (redness) of intact skin Stage 2- Partial thickness skin loss epidermis (outer layer of skin), dermis (second layer of skin), or both. The ulcer is superficial (surface), clinically seen as an abrasion or shallow crater. Stage 3-Full thickness skin loss involving damage to, or necrosis of subcutaneous tissue that may extend down to, but not through fascia (band of tissue beneath the layers of the skin that binds to muscle). The ulcer presents clinically as a deep crater with or without undermining (destruction) of adjacent tissue. Stage 4-Full thickness skin loss with extensive destruction, tissue necrosis damage to muscle, bone or supporting structure (tendon, joint capsule). Undermining and sinus tracts may be present. Unstageable- if ulcer is covered by eschar (dead tissue), it cannot be staged. Review of Resident 10's acute care hospital discharge summary for the 10/8/15 discharge from the acute care hospital, completed by Resident 10's orthopedic surgeon (Physician P), indicated Resident 10 was admitted to the acute care hospital on 10/4/15 for dislocation of a right hip. On 10/5/15, Resident 10 underwent surgery to repair the dislocation and was to return to the skilled nursing facility with an immobilizer brace. The discharge summary indicated staff were to keep the immobilizer on Resident 10's right knee at all times, particularly with any kind of transfers and ambulation, but the brace could be removed for hygiene purposes. Instructions included Physical Therapy (PT) staff were to look carefully for changes in rotation of her right lower extremity as well as leg length discrepancies, and the knee immobilizer would remain on for six weeks. Resident 10's skilled nursing facility physician's orders, dated 10/8/15 to 10/18/15, completed by Medical Director, Resident 10's treating physician in the skilled nursing facility, indicated: WBAT (weight bearing as tolerated), leave immobilizer on. There were no orders regarding removal of the brace or for care of the skin as mentioned in the discharge summary. Resident 10's nursing progress notes, dated 10/8/15 at 11 a.m., indicated Resident 10 was admitted to the skilled nursing facility from the acute care hospital at 10:21 a.m., with a surgical site incision on the right hip; an unable to be determined stage (due to presence of necrotic tissue in the wound bed) pressure ulcer on the coccyx. There was no documentation regarding the knee immobilizer on the resident; or assessment of the skin under the immobilizer or care plan related to care of the brace or how skin would be assessed under the brace. On 10/10/15 at 9:49 p.m., nursing progress notes indicated Resident 10's right hip dressing and the brace was on. There was no documentation of a skin assessment under the brace, or clarification of orders related to the brace. On 10/11/15 at 12:25 p.m., Licensed Staff S (wound care nurse) note documented the resident's right foot had increased edema (swelling) with bruising noted just above the lateral (side) ankle and on the posterior aspect (back side). Licensed Staff S noted a skin tear on the lateral aspect of the lower leg found under a Kerlix dressing (gauze dressing) which measured 3 cm x 1 cm. The note documented the area was cleansed and a new dressing was applied for protection and foam was placed at the bottom of the immobilizer to protect the skin. Licensed Staff S documented the charge nurse was notified of the pedal (lower extremity) edema. There was no documentation of notification to the doctor of the skin tear at this time; clarification of orders related to removal of the brace for skin assessments; assessment as to the cause of the wound or if it was a stageable pressure ulcer. A nursing order, documented by Licensed Staff S, dated 10/12/15 at 1:29 p.m. indicated to monitor under the immobilizer brace and placement of foam protection at proximal and distal ends of the right leg immobilizer every shift. There was no care plan in the record related to monitoring under the immobilizer brace, placement of foam or specific instructions for removal of the brace. Review of Resident 10's physician orders, dated 10/13/15-11/08/15, documented an order from Resident 10's physician (Medical Director) to cleanse a skin tear to the right lower leg with normal saline and dry and apply alginate (a gel that helps absorb wound drainage) and cover with dry gauze dressing until resolved once a day . Review of Resident 10's orders, effective 10/18/15 to 11/13/15, from Resident 10's orthopedic surgeon (Physician P) indicated total hip precautions, WBAT, leave immobilizer on, except can remove during PT/OT(Physical Therapy / Occupational Therapy) sessions for ROM (range of motion) and strengthening only. Another order by Physician P, effective 10/19/15 to 11/13/15 documented therapy may remove the immobilizer only to do ROM and strengthening. The orders did not clarify removing of the brace to conduct skin assessments or for protection of the skin under the brace. During an interview, on 2/3/16 at 3:45 p.m., Licensed Staff T stated Resident 10 had the immobilizer brace on when she came back from the hospital on 10/8/15. Licensed Staff T stated it depended on the orders if staff removed the brace. Licensed Staff T stated "normally" nurses opened the brace to assess the skin under the brace. Licensed Staff T stated she did not take the brace off when she initially took care of Resident 10. Review of nursing notes from 10/10/15 to 10/11/15 indicated there was no skin assessment under the brace. There was no clarification of orders to remove the brace to assess skin under the brace until 10/12/15 when there was a nursing order placed by the wound care nurse (Licensed Staff S) to monitor the skin under the immobilizer and placement of foam protection at the proximal and distal ends of the the right leg every shift. During a telephone interview, on 2/4/16 at 11:30 a.m., and concurrent review of Resident 10's record, Licensed Staff R (a wound care nurse) stated Resident 10 had a brace on her right leg when she was admitted on 10/8/15. Licensed Staff R described the brace had metal strips in the fabric that ran down the back of the knee as well as metal strips that were on each side of the knee, Velcro straps held the splint in place. The splint went from the groin (the area from the hip between the stomach and thigh) to the ankle. Licensed Staff R stated the record indicated the other wound care nurse, Licensed Staff S documented the wound care note on 10/11/15 regarding identification of the skin tear which was covered with the Kerlix (gauze wrap) dressing. Licensed Staff R stated there should have been a care plan in place for removal of the brace which she did not see in the admission care plans or a physician order to remove the brace. Licensed Staff R stated usually the ADON (Assistant Director of Nurses) assessed the skin on admission or the DSD (Director of Staff Development). During an interview, on 2/4/16 at 3:30 p.m., the Director of Staff Development (DSD) stated she usually entered admission data in the computer and started the care plans. DSD stated she did not physically see Resident 10 when the resident was admitted and stated Licensed Staff R did the skin assessment. DSD stated she documented in the admission record what Licensed Staff R told her. DSD stated she did not see a care plan for skin integrity started on admission for Resident 10. She stated usually when a resident had a brace; she customized the skin integrity care plan to include checking the skin under the brace. She stated the treatment orders should include this protocol at least every shift. DSD stated a treatment order was initiated on 10/12/15 to monitor skin under the brace. DSD stated she thought Licensed Staff R started the care plan. DSD stated she did not note there was a brace or care plan upon admission for Resident 10 for its removal and assessment of skin underneath the brace. During a telephone interview and record review, on 2/8/16 at 8:25 a.m., Licensed Staff S (second wound care nurse) stated she first saw Resident 10 on 10/11/15. She stated Resident 10 had an immobilizer brace on her leg. Licensed Staff S stated she removed the brace and checked Resident 10's skin and saw some bruising on the right lower extremity on the calf and padded the brace with low profile foam. Licensed Staff S stated she saw a Kerlix dressing on the right lower leg and when she removed the dressing, she noted a skin tear under the dressing. Licensed Staff S stated she did not know when the Kerlix dressing was originally placed and stated the admission nurse should have noted it. Licensed Staff S stated she obtained a treatment order from Resident 10's physician (Medical Director ) to cleanse the skin tear with normal saline, apply calcium alginate (a gel type dressing that assists to absorb wound drainage and debris) and cover with a dry dressing until resolved. Licensed Staff S stated the Wound Care Physician (Physician Q) had been in for treatment for Resident 10's sacral and surgical wounds, but he did not see Resident 10's leg wound until 11/2/15, when it had become unstageable with necrotic tissue. Licensed Staff S stated 11/2/15 was the first time Physician Q saw the wound and that was when Physician Q performed the surgical debridement of the wound. Licensed Staff S stated Physician Q did not see the resident on 11/9/15 as scheduled and the resident was transferred to the acute care hospital on 11/13/15 due to altered mental status, increased pain and low blood pressure. Licensed Staff S stated Resident 10's leg wound should have been assessed every shift. Licensed Staff S stated there was no nursing care plan until 10/23/15 to check the skin under the brace for Resident 10 and stated that should have been done upon admission. Licensed Staff S stated care plans should be updated on an as needed basis. A wound care nurse's (Licensed Staff R) note, dated 10/23/15 at 9:21 a.m., indicated Resident 10's right leg brace caused irritation to the resident's right lower leg. The note documented the use of foam pads on top of the brace and at the bottom to help with the prevention of irritation/ rubbing. The wound care note documented Resident 10 had a "rubbed" area, which measured approximately 7.5 cm length x 3.5 cm width x approximately .3 cm depth. The note documented "will have" the wound care physician assess this Monday [10/26/15]. The note documented the physician and the responsible party was aware. There was no documentation of an assessment of the stage of the wound, description of the wound bed, an assessment by the physician or evaluation of the immobilizer brace. A treatment order, dated 10/23/15 to 11/2/15, indicated once a day treatment to the irritation / rubbed area "related to the leg brace", cleanse with normal saline, dry, apply wound gel, cover with gauze and foam, then wrap with Kerlix every day. Notify MD (medical doctor) of any negative changes. "Wound care physician to assess next visit" was written under special instructions. The treatment administration record indicated, by placement of initials, that the wound treatment was administered every day through 11/2/15, except for 10/24/15 when the resident was not available. There was no documentation in the treatment records of ongoing assessments of the wound during these treatments to evaluate for changes in the wound or need to alter treatment. Review of Nurses progress notes, dated 10/23/15 through 11/3/15, indicated one note dated 10/31/15, that described the leg wound, from Licensed Nurse R (wound care nurse) that resident continued on treatment for the leg brace irritation, that there was bilateral four plus pitting edema in the ankle (measurement of the severity of fluid in the tissue, by the indentation left when the ankle area was pressed), no odor from the wound, scant yellow drainage and the center of the wound with loosening necrotic tissue. Outer edges with red beefy tissue. No s/s (Signs or symptoms) of infection, just a lot of pain being noted, will continue to monitor daily. The note indicated Physician Q, the wound care physician would assess the patient the day after the next day (11/2/15). A physical therapist progress note, also dated 10/31/15, indicated Licensed Nurse R did a treatment to Resident 10's calf wound. The physical therapist note documented the wound was approximately "2.5 x 1.5 inches [approximately 6.35 cm x 3.81 cm] and full thickness with eschar (dead tissue) noted along the lateral border into the midline of the wound." A nurse progress note, dated 11/2/15, documented Physician Q (the wound care physician) examined the ulcer on Resident 10's posterior right calf and the area measured 7.5 x 5 x 1 cm after sharp debridement. The immobilizer worn on the leg had been padded since it was first applied and skin checks were being done every shift. Skin was extremely fragile and Physician Q states the wound was "unavoidable". Review of the acute care hospital "Emergency Department Physician Note", dated 11/13/15, indicated Resident 10 presented to the acute care hospital emergency room from the skilled nursing facility with an altered mental status. Resident 10 had a large ulcer on her right calf. The final diagnosis included sepsis (severe, life threatening infection spread by the blood stream) due to an unspecified organism, and pneumonia of the right lower lobe and a Stage 4 pressure ulcer of the leg. During a telephone interview, on 2/9/16 at 9:28 a.m., the Medical Director (Resident 10's treating physician in the skilled nursing facility) stated the nurses entered the order for skin treatment of the leg in the computer and stated he had never seen the wound on the leg. The Medical Director stated he understood the wound care doctor (Physician Q) did the wound care on the leg. The Medical Director stated Resident 10 had the brace on when she was admitted, but staff were supposed to check under the brace, and the orthopedic physician wrote it could be removed for hygiene purposes. The Medical Director stated there was always a chance for skin breakdown under the brace. The Medical Director stated that the nurses should have had a care plan for the brace as the resident was "new to the brace". The first note written by Physician Q regarding the right lower extremity wound was on 11/2/15, which indicated it was an unstageable wound due to necrosis (dead tissue). The wound size was 7.5 x 5 cm with moderate serous exudate (wound drainage) and 100% thick necrotic tissue. The note indicated the physician did a surgical debridement, removing necrotic tissue along with muscle. During a telephone interview, on 2/11/16 at 9:10 a.m., Physician Q stated the pressure sore could be determined unavoidable if you could not remove the brace as it could cause damage to the hip, but stated nurses should follow their protocols for assessing the skin. During an interview, on 8/4/16 at 9:00 a.m., the Medical Director stated that unavoidable pressure sore would mean everything was done to avoid the pressures sore, and he expected staff should have had a plan of care for brace removal and the policy for pressure sores should be reviewed. Review of documentation of a visit by the Medical Director, dated 11/13/15, indicated Resident 10 had severe pain in the right leg that was not relieved with pain medication and a "wedge rubbing holes in her legs". The visit note documented the wound on Resident 10's shin was clean with fair granulation tissue and the resident was referred back to the ER for re-evaluation for injury/dislocation vs. DVT ( blood clot in leg). During an interview, on 8/4/16 at 9:15 a.m., Licensed Staff S stated nurses should assess under a leg brace everyday if ordered and record results weekly. Licensed Staff S stated the wound care doctor did not evaluate unless there was a problem with the skin under the brace. The wound care nurse stated they did not have a policy on the removal of the brace and stated she had never reviewed the policy and procedure for pressure sore assessment and interventions for prevention of pressure sores. Licensed Staff S stated the nurse should develop a care plan to ensure other nurses know what to do and do the same care. During an interview, on 8/5/16 at 12 p.m., the Administrator stated the facility could individualize corporate policy and procedures for the facility's needs and agreed Licensed Staff S should have read the policy and procedure. The Administrator stated they went over policies routinely and tell the Medical Director what they are about and the Medical Director signs them. On 8/5/16, review of the facility policy and procedure, revised 2013, for Pressure Ulcer Risk Assessment, provided guidelines for the assessment and identification of residents at risk of developing pressure ulcers. The policy noted pressure can come from splints, casts, bandages and wrinkles in bed linen. If pressure ulcers are not treated when discovered, they have the potential to become larger, painful and infected. The policy indicated residents at risk need to be identified and have interventions implemented immediately to attempt to prevent pressure ulcers. The admission evaluation helped to define the initial care approaches and interventions. Care Planning and interventions should be individualized for the resident according to their risk factors. Review of the Pressure Ulcers Skin Breakdown policy, revised September 2013, indicated the nurse and the attending physician assesses and documents an individuals's significant risk factors for developing pressure sores. In addition, the nurse should describe and document / report a full assessment of the pressure sore including location, stage, length, width, and depth and presence of exudates or necrotic tissue. The nurse will examine the skin of a new admission for ulcerations or alterations in the skin. Under monitoring, the physician will help the staff review and modify the care plan as appropriate, especially when the wounds are not healing as anticipated or new wounds develop despite existing interventions. The facility policies and procedures contained no specific nursing interventions for the prevention of pressure sore development under a brace. Review of National Pressure Ulcer Advisory Panel Quick reference Guide, published 2014, indicated to inspect the skin under and around medical devices at least twice daily for the signs of pressure related injury in the surrounding tissue. The guide indicated to conduct more frequent skin assessments grater than 2 X a day at the skin surface if resident is prone to localized or generalized skin edema. The guidelines indicated to access the pressure ulcer initially and reassess it at least weekly. The guidelines indicated with each dressing change to observe the pressure ulcer for signs that indicated a change in treatment was required, such as wound improvement, wound deterioration, more or less exudates, signs of infection or other complications and to address signs of deterioration immediately such as increase in wound, tissue quality, increase in exudates or clinical signs of infection. Therefore, the facility failed to provide Resident 10 with necessary treatment to prevent the development and progression of a pressure ulcer. The facility failed to ensure a care plan was developed upon admission for care of the resident's skin under her leg immobilizer brace (splint to prevent movement of the leg); failed to ensure ongoing skin and wound assessments after wound dressing changes in order to determine effectiveness of treatment and in accordance with standards of practice; failed to develop policies and procedures for ongoing wound assessments and prevention of pressure ulcers for residents with a leg brace/immobilizer; failed to ensure a physician assessed and evaluated the resident's wound under her brace before the wound became necrotic and deteriorated to an unstageable wound with necrotic tissue which required surgical debridement. These failures presented either imminent danger that harm would result or a substantial probability that serious harm or death would result. |
| 010000082 |
Redwood Cove Healthcare Center |
110012555 |
B |
13-Sep-16 |
1BC912 |
5286 |
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. 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. 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. 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. 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 easily 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." The facility failed to post Class A Citation #11-2813-12375 that was served to the facility on 7/29/16 in the locations and manner as specified by the Health and Safety Code. This violation resulted in an automatic "B" Citation. During an observation, on 8/15/16 at 9:20 a.m., of the facility's lobby, nurse's station, residents' dining room and activity room, and the employee break room, there was no "A" Citation posted. During an observation and concurrent interview, on 8/15/16 at 9:30 a.m., there was a white binder in a slot on the wall across from the nurse's station which indicated "Survey Binder". The Administrator stated the binder was where she placed the copy of Citation #11-2813-12375. In the binder, the "A" Citation #11-2813-12375, served to the facility on 7/29/16, was placed behind the facility's recent federal surveys. The Administrator confirmed this was the only location in which the Citation was placed and stated she was not aware of the posting requirements. The facility failed to post Class A Citation #11-2813-12375, served to the facility on 7/29/16 in the locations and manner as specified by the California Health and Safety Code. This violation resulted in an automatic "B" Citation. |
| 010000082 |
Redwood Cove Healthcare Center |
110013184 |
A |
30-May-17 |
QZNA11 |
18455 |
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 follow the care plan and implement the use of an assistive device (mechanical lift) to prevent avoidable accidents for Resident 14, identified by the facility as at risk for falls, when transferring the non-ambulatory (not able to walk) resident from the bed to a shower chair. Two CNA's (certified nurse assistants) transferred Resident 14 by hand. Resident 14 became too heavy for the two CNA's to hold and had to be lowered to the floor. Resident 14 sustained a right femur (long bone of the thigh) spiral fracture (a break in a bone that typically occurs when a rotating force is applied along the length of the bone.) Resident 14 required hospitalization and surgical repair of the fracture.
Resident 14 was XXXXXXX year old female originally admitted to the facility on XXXXXXX 10. Resident 14's Face Sheet (an admission record) indicated she had multiple diagnoses which included a history of cerebral vascular accident (CVA [stroke] - loss of blood flow to the brain) with residual right sided hemiparesis and hemiplegia (weakness and paralysis-loss of muscle function), vascular dementia (loss of memory and other functions of daily living due to reduced blood flow to the brain from vascular disease within the brain) and osteoarthritis (a type of arthritis [inflammation] that occurs when the flexible tissue [cartilage] at the ends of bones wears down.)
Resident 14's Care Plan for falls, dated 3/2/14, indicated Resident 14 was "at risk for falls secondary to history of fall, dementia, impaired mobility with need for extensive assist with cares." Approaches to prevent falls were to "monitor factors causing prior falls," and to place a "fall mat" beside bed to minimize impact of falls. An updated approach to prevent falls, dated 4/10/15, directed staff to use "two person assist with mechanical lift (use of a sling, attached to a hydraulic lift device, which is placed under the patient and once firmly secured can move a patient from one place to another)." The long term goal indicated, Resident 14 would remain free of injury as evidenced by being free of falls or accidents every day for 90 days. Long term goal target dates were updated and entered as 5/27/16, 9/7/16, 11/24/16, 2/3/17, and 2/22/17.
Resident 14's quarterly fall risk assessment dated 11/26/16, indicated a score of 17. A score of greater than 13 indicated a high risk for falls, per the Johns Hopkins Health System Fall Risk Assessment Tool, which the facility utilized.
Resident 14's quarterly Minimum Data Set (MDS - a resident assessment tool) dated 11/27/16, indicated Resident 14 did not ambulate and required "total dependence" of two or more staff persons during transfers. Resident 14 was not able to complete a Brief Interview for Mental Status (BIMS) due to her cognitive impairment and was "rarely/never understood."
The nursing progress note dated 12/25/16 at 11:19 p.m., (recorded as a late entry on 12/30/16 at 3:12 p.m.) indicated the licensed nurse (LN D) was called to Resident 14's room on the evening of 12/25/16. The progress note indicated, "Staff sitting on floor with resident keeping her in semi-Fowler's position (sitting upright at a 30-45 degree angle.) Staff stated they went to the floor with resident during transfer from bed to shower chair." LN D assessed Resident 14 and no deformity of her arms, legs, spine or neck was observed. Resident 14's level of consciousness and range of motion to her legs was described as "per baseline," (same as before the fall.) LN D did not observe signs or symptoms of injury or pain during subsequent "every 30 minutes" assessments. It was noted that Resident 14 was "non-ambulatory, bedbound, with limited verbalization." LN D's progress note also noted, "to be endorsed (reported) to oncoming nurse (next shift licensed nurse) for continued assessment. Will continue to monitor."
The nursing progress note dated 12/29/16 at 5:57 a.m., indicated LN E was called, by a CNA, to Resident 14's room "around 4:40 a.m." on 12/29/16. Resident 14's right leg had "yellowish discoloration" on the right knee and "reddish discoloration" to the right shin. LN E noted, upon assessment of Resident 14's right leg, Resident 14's "facial reaction was in pain by moaning and grimacing." LN E documented Resident 14's right leg was shorter than the left leg. The progress note indicated Resident 14's physician and family were notified.
Review of an Interdisciplinary Team (IDT) note for Resident 14, dated 12/30/16, indicated the IDT met on 12/30/16 at 10:25 a.m. to review "Events, 12/25/16 Falls / Found on Floor." The team consisted of the Administrator, DON, MDS nurse, DSD (Director of Staff Development) nurse, an Occupational Therapist, the Activities Director, and the Medical Records Director. The IDT progress note indicated Resident 14 had no significant changes noted prior to the "intercepted" (to obstruct or catch someone or something) fall on 12/25/16. The IDT note documented Resident 14 sustained a right femur acute spiral and displaced fracture of the mid femoral shaft. The "Root Cause," (the most basic cause that can be identified, and when fixed, will prevent or significantly reduce the likelihood of the problem's recurrence) evaluated by the IDT revealed, "Two CNA staff attempting to get res (resident) up when res slipped during transfer, assisted to floor with R (right) leg impact." There was no mention, in the IDT's Root Cause evaluation, of the CNA staff not using the mechanical lift for Resident 14's transfer, as per her care plan.
A rehab post (after) fall screen for Resident 14 was performed by Occupational Therapist F on 12/29/16 at 11:36 a.m. Details of the report revealed no assistive device was used on 12/25/16 during Resident 14's transfer from bed to shower chair. Concurrent review of Occupational Therapist F's progress note dated 12/29/16 at 11:37 a.m., (recorded as late entry on 12/30/16 at 9:40 a.m.), indicated, during the rehab post-fall screen on 12/29/16, Resident 14 had facial grimacing and cried out with "PROM" (Passive Range of Motion - moving the joints through a range of motions without help from a resident) to her "RLE" (right lower extremity). The RLE was in "external rotation" (turning outward or away from the midline of the body).
During an interview on 1/25/17 at 11:55 p.m., the Director of Nursing (DON) stated, on 12/25/16, during the evening shift (typically 2:30 p.m. to 11 p.m.) Resident 14 was being transferred "manually" (by hand) from her bed to a shower chair by two CNA's. Resident 14's "knee buckled (collapsed)" and the two CNA's assisted her to the floor. A few days later, on 12/29/16, the DON stated a night shift nurse (LN E) noticed Resident 14's legs were "not even." When asked if Resident 14 indicated she was in pain, the DON stated at times it was difficult to tell if Resident 14 had pain due to her dementia. The DON stated an X-ray of Resident 14's right leg/hip was taken on 12/29/16 which revealed "an acute (sudden onset) spiral and displaced fracture (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of the right femur." The DON confirmed Resident 14 was sent to the hospital on XXXXXXX16.
Review of the hospital's surgery notes titled, Surgery and Procedure Reports, dated 12/31/16 at 12:02 p.m., indicated on 12/30/16, Resident 14 underwent an open reduction and internal fixation (ORIF) of the right femur. ORIF is surgery to fix the broken bone. Open reduction means the bone is moved back into the right place with surgery. Internal fixation means that hardware (such as rods or pins) is used to hold the broken bones together (www.allinahealth.org). Resident 14's surgery to repair and stabilize the fractured right femur required surgical placement of a plate, screws, and cables.
During an interview on 1/25/17 at 2 p.m., when asked if all two-person transfers utilized a mechanical lift, Licensed Nurse S (LN S) stated, "Yes, but therapy [physical or occupational] determines the level of transfer and it depends on the resident [condition / diagnosis]."
During an interview on 1/25/17 at 2:15 p.m., when asked when a mechanical lift was used, CNA A stated, "when a resident is not able to stand or bear weight."
During an interview and observation on 2/8/17 at 3:15 p.m., CNA B stated she was assigned to take care of Resident 14 on the evening shift of 12/25/16. CNA B stated it was Resident 14's shower day and CNA B pressed the call light for help to transfer Resident 14 from her bed to the shower chair. CNA C responded to the call light. When asked what type of transfer the two CNA's performed, CNA B stated, "we do it manually" (by hand). CNA B stated she and CNA C had Resident 14 "under her arms" during the transfer, when CNA B stated Resident 14 was "too heavy." CNA B stated, "so we lowered her [Resident 14] to the floor." When asked if Resident 14's knee's "buckled," CNA B stated, "No, she was just heavy so we slowly let her down and one of us stayed with her and the other one called for the nurse." When asked if Resident 14 showed any signs of being in pain, CNA B stated, "No, she seemed as usual ... she didn't hit the ground." CNA B demonstrated the position that Resident 14 was in after being lowered to the floor: a sitting position with both legs bent or folded to one side.
During an interview on 3/9/17 at 11:15 a.m., when asked why a mechanical lift was not used on 12/25/16 when transferring Resident 14 to the shower chair, the DON stated she consulted with the Director of Staff Development (DSD), who interviewed CNA B and CNA C after the fall, and the CNA's stated, "because it was quicker to do it manually."
During a subsequent interview on 4/11/17 at 9:30 a.m., the DSD confirmed no mechanical lift was used to transfer Resident 14 because CNA B and CNA C told her it was faster to do it manually. When asked if Resident 14 was always transferred "manually" the DSD stated, "If it was with those two (CNA's), probably."
During an interview on 3/13/17 at 3:30 p.m., Resident 14's nursing progress notes, dated between 12/26/16 and 12/28/16, were requested of the DON. The DON stated there were no nursing progress notes for this time period (except for a weekly summary dated 12/28/16 at 3:51 a.m. that did not mention Resident 14's fall.) The DON stated she became aware of Resident 14's "assisted" fall of 12/25/16 when, on 12/29/16, Resident 14 "showed bruising" and licensed staff had obtained a physician's order for an X-ray of the right hip. The DON stated she asked her nursing staff, "What happened?" The DON stated that was when LN D informed her of Resident 14's "intercepted" fall on 12/25/16. The DON stated she told LN D to document the event in the progress notes (refer to progress note above, dated 12/25/16 at 11:19 p.m., recorded as a late entry on 12/30/16 at 3:12 p.m.) During concurrent review of Resident 14's nursing progress notes, the DON confirmed it was on 12/29/16 that the progress notes reflected the development of pain and bruising to Resident 14's right leg with the subsequent order for an X-ray which revealed an acute fracture of the right femur.
During an interview on 3/14/17 at 8:19 a.m., LN E stated she was called into Resident 14's room on 12/29/16 "between 4:30 and 5 a.m." by a CNA who asked her to check the resident's right leg. LN E stated she discovered "discoloration" to Resident 14's right knee and shin and "the right leg was shorter than the left leg." LN E stated she assessed Resident 14 with PROM to her right leg and Resident 14's face grimaced and she moaned. LN E stated Resident 14 did not have a response to PROM to her left leg. LN E stated she faxed a report to Resident 14's physician and requested an X-ray be taken. LN E also informed Resident 14's family. When asked if any staff reported Resident 14's fall on 12/25/16, LN E stated, "No, I had no knowledge she had a fall."
During an interview on 3/14/17 at 3:20 p.m., LN D stated she was called into Resident 14's room by a CNA on the evening of 12/25/16 (exact time unknown). LN D stated there were three to four CNA's in Resident 14's room, to help, but Resident 14 was "on the lap" (the flat area between the waist and the knees) of one of the CNA's and they were sitting on the floor. LN D described Resident 14's position as "a sitting position with her knee's bent to one side." LN D stated Resident 14's position did not look malformed. LN D stated a CNA's told her, "she gave out," referring to Resident 14's transfer, and the CNA's "went down with her" and "she never hit the floor." LN D stated she assessed Resident 14, while still on the floor, for any deformity of extremities, bruising, pain and her level of consciousness and there were no indications of injury. Resident 14 was then lifted to the shower chair, given a shower, and LN D stated she checked Resident 14 "visually and physically" every 30 minutes and "no changes" were observed. When asked if she documented the incident, LN D stated, "No ... I didn't chart on time" and confirmed she wrote a "late entry" note dated 12/30/16 of the incident that occurred on 12/25/16. When asked if she documented Resident 14's "every 30 minute assessments" after the fall on 12/25/16, LN D stated, "No, not documented ..." LN D stated she did not inform the DON or Resident 14's physician at the time of the incident on 12/25/16. When asked if she reported the event to the oncoming night shift nurse (LN E), LN D stated, "I want to say yes 100% but I can't recall the conversation ... I can't imagine not telling the next nurse." When asked if the CNA's used a mechanical lift when transferring Resident 14 from the bed to the shower chair, LN D stated the CNA's did not use the mechanical lift.
According to Potter and Perry's Fundamentals of Nursing, ninth edition, 2017, Principles of Safe Patient Transfer and Positioning, "Mechanical lifts and lift teams are essential when a patient is unable to assist."
During a telephone interview on 4/12/17 at 8:40 a.m., when asked if she assessed Resident 14 as requiring a mechanical lift for transfers, Occupational Therapist F stated "Not previously [before the fall], it was used after [the fall]."
Review of the hospital's examination report, titled "History and Physicals," dated 12/29/16, indicated Resident 14 was brought to the Emergency Department (ED) on 12/29/16 due to "severe right leg pain" after a "mechanical fall." Upon physical examination, Resident 14's right hip was painful to palpation (touch) and had swelling. There were "ecchymoses (bruises) over her upper body." Concurrent review of the orthopedic surgeon's Consultation, dated 12/30/16, indicated "Prior to the fracture, the patient (Resident 14) did not ambulate."
Review of the acute care hospital's interfacility (from one facility to another) transfer record dated 1/3/17 (the date Resident 14 was discharged from the hospital and re-admitted to the skilled nursing facility) indicated Resident 14's prior level of function (before being admitted to the hospital) was documented as "Dependent" and she was "Unable" to transfer independently.
The facility's policy titled, "Safety and Supervision of Residents," revised 12/07, indicated a policy statement, "Resident safety and ... assistance to prevent accidents are facility-wide priorities." The "Resident-Oriented Approach to Safety," indicated "#4. Implementing interventions to reduce accident risks and hazards shall include ... communicating specific interventions to all relevant staff," and "#5. Monitoring the effectiveness of interventions shall include ... ensuring that interventions are implemented correctly and consistently."
The facility's policy and procedure titled, "Falls and Fall Risk, Managing," revised 12/07, indicated a Policy Statement, "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 "Policy Interpretation and Implementation/Prioritizing Approaches to Managing Falls and Fall Risk," indicated, "The staff ... will identify appropriate interventions to reduce the risk of falls," and " ... staff will identify and implement relevant interventions ... to try to minimize serious consequences of falling." The section of the policy and procedure subtitled, "Monitoring Subsequent Falls and Fall Risk," indicated "The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling."
The facility failed to follow the care plan and implement the use of an assistive device (mechanical lift) to prevent avoidable accidents, for one of 14 sampled residents (Resident 14), identified by the facility as at risk for falls, when transferring the non-ambulatory (not able to walk) resident from the bed to a shower chair. Two CNA's (certified nurse assistants) transferred Resident 14 by hand. Resident 14 became too heavy for the two CNA's to hold and had to be lowered to the floor. Resident 14 sustained a right femur (long bone of the thigh) spiral fracture (a break in a bone that typically occurs when a rotating force is applied along the length of the bone.) Resident 14 required hospitalization and surgical repair of the fracture.
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. |
| 630013665 |
Ridgecrest Regional Transitional Care and Rehabilitation Unit |
120010430 |
A |
10-Feb-14 |
H59X11 |
20870 |
CFR 483.13 (F224): The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. NOTE: Pressure Sores (aka Bed Sores, Decubitus Ulcers, and Pressure Ulcers) are areas of damaged skin caused by staying in one position for too long. They commonly form where bones are close to the skin, such as ankles, back, elbows, heels and hips. A person is at risk if bedridden, or unable to change position. Pressure sores can also cause serious infections, some of which can be life-threatening. From the National Pressure Ulcer Advisory Panel, or NPUAP: Pressure sores are measured in Stages and grouped by their severity. Stage I is the earliest stage. Stage IV is the worst. Stage I: A reddened area on the skin that, when pressed, does not turn white, also known as non-blanchable. This is a sign that a pressure ulcer is starting to develop. Stage II: The skin blisters or forms an open sore.Stage III: The skin now develops as an open, sunken hole.Stage IV: The pressure ulcer has become so deep that there is damage to the muscle and bone under the skin, and sometimes even to tendons and joints.Unstageable: Full thickness loss in which the ulcer is completely obscured by discolored tissue that may be 'dead' and black. Until enough of this discolored tissue can be removed to expose the base of the wound, the true depth cannot be determined; but it will be considered a Stage III or IV.(Suspected) Deep Tissue Injury (SDTI): Depth Unknown. The area may be preceded by tissue that is painful, firm, or mushy.Based on interview and record review, the facility neglected to provide services necessary to prevent two (2) deep tissue injuries (DTI), and one (1) unstageable pressure sore from forming on one of one sampled residents (Resident A) during a five (5) day stay at the facility. Resident A had previously been cared for at home by her family, with the assistance of a home health and hospice agency (one that specializes in end-of-life care). On their advice, the family admitted Resident A to the facility for a planned 5-day stay to give the family member "a break."After the five days were over, Resident A was discharged back home with three, new wounds that were not present on admission to the facility. These three wounds were: 1) a DTI on her sacrum (tailbone area), 2) a DTI on her right heel, 3) an unstageable pressure sore on her right lower calf. These wounds resulted in actual physical harm to Resident A. Findings: During a review of the clinical record for Resident A, it was documented she first arrived at the facility in the morning of 8/9/13 from her home, then discharged back home on the afternoon of 8/13/13, for a facility stay totaling five (5) days. Nursing Progress Notes, dated 8/12/13, at 10 AM, indicated Resident A had a diagnosis of end stage dementia. She had been bed ridden for 5 years, and had an above the knee amputation to one leg while the other leg was contracted causing her foot to rest on the peri area (area between the vagina and anus.)During an interview with Family Member 1 (FM 1) on 9/11/13 at 9:15 AM, she indicated she had been taking care of Resident A for the last five (5) years or so, and a local home health and hospice agency has been coming to her home three to five times a week for the last several months to assist with feeding, dressing, and bathing.FM 1 indicated that, at the advice of the home health and hospice agency, she agreed to admit Resident A to the facility for a five (5) day stay, in order to give her respite, or "a break" in providing daily care for Resident A. FM 1 stated "I'd been caring for her for so long without a break." FM 1 indicated Resident A's skin at the time of admission to the facility was clear, stating "there were no sores on her" prior to 8/9/13, except for a small scab on her right knee. FM 1 indicated, however, upon returning home from the facility five (5) days later on 8/13/13, Resident A had "two really, really bad, black bedsores, one on her ankle and one on the back of her leg, and also an area on her coccyx [tailbone]. She was ordered a special air mattress, but it took 2 or 3 days before she actually got it." FM 1 indicated Resident A was transported to and from the facility via ambulance.During an interview with a facility Registered Nurse 1 (RN 1) on 9/13/13, at 2:30 PM, she indicated she remembered Resident A being at the facility. RN 1 stated "I remember her. She was hospice care, here over a long weekend for respite care." RN 1 stated there was "nothing on her heel at admit." RN 1 indicated she recalled Resident A having only one leg (her left leg had been amputated above the knee some years ago) and now, her remaining right leg was contracted, or drawn together at the knee, into a position where she would essentially be sitting on her heel. RN 1 indicated she believed it was possible this contracted position contributed to her wound(s).During a review of the clinical record with RN 1, the document titled "Admission Assessment Report", dated 8/9/13, indicated "Heel Assessment - Clear", her left knee was "scabbed over", and "Coccyx Assessment - Red, blanchable" (meaning Resident A's skin would turn white when pressed with a finger, and, according the Centers for Medicare and Medicaid Services - recognized NPUAP, does not meet the criteria for a Stage 1 pressure sore, as only "non-blanchable skin does). There were no entries indicating an issue with Resident A's calf, or the back of her lower leg.The document titled "Physician's Admitting Orders" dated 8/9/13, read under "Treatment - knee wound - leave open to air." There were no admitting orders for any other areas. There was an additional "Physician's Telephone Order" dated 8/10/13 for "Calazyme Topical Cream - apply to intact / irritated skin for skin barrier."The facility policy & procedure titled "Skin Care Protocols/Procedures", dated 5/30/12, was reviewed. It read, in part, that facility nursing staff "shall initiate pressure ulcer management guidelines..., or consult Certified Wound Specialist (CWS) for at-risk patients on admission... The following conditions create at-risk patients [partial list]: immobility, incontinence, malnutrition, altered mental status, peripheral / arterial disease." The document titled "Progress Notes Report", dated 8/12/13, at 1:17 PM (Resident A's fourth day at the facility), the first entry by a CWS was noted, and read: "Wound care: Hospice Patient with multiple sDTI [suspected deep tissue injury] deep purple and red color R & L trochanter [bony prominence at hips], sacrum [tail bone] (pear shaped), and heels [sic]. Left AKA [above knee amputation], right leg contracted to buttock. Right calf unstageable pressure caused by femur [thigh bone] due to contracted leg. Right knee eschar with wound odor noted."Another entry was made on 8/13/13, at 8:05 AM, which read "Pt noted to have DTI on buttocks, and on heel of right foot. Hospice was told and stated they will inform family."The document titled "Licensed Nurse Progress Notes" dated 8/12/13, and written by RN 1 was reviewed. It read Resident A was "noted to have pear shaped area of red blue discoloration approx. 6 X 6 centimeters [cm] with no depth on sacrum [tail bone], and an area of red blue discoloration approx. 3 X 6 cm with no depth on heel. Admission Assessment notes red area on coccyx. Res is on a lateral rotation mattress. Hospice Nurse [Manager] RN notified & she stated she would inform family. She has been bedridden 5 years & has severe contractures, poss. due to end stage dementia. Her leg is folded up behind her with the foot resting on the periarea [area between the thighs] & buttocks."The document titled "Minimum Data Set" (MDS, a comprehensive assessment tool), with an assessment reference date of 8/13/13, was reviewed. The MDS indicated Resident A had, by that date, two (2) "unstageable pressure ulcers with suspected deep tissue injury in evolution." However, the MDS indicated these two areas were not present at time of Resident A's admission to the facility.The MDS indicated Resident A's cognitive skills for daily decision making were "severely impaired - never/rarely made decisions", and had "Altered level of consciousness", and that the "Behavior was continuously present, does not fluctuate." The MDS also indicated she required "extensive assistance... staff provide full weight - bearing support" for the activity of bed mobility (how the resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). The MDS indicated Resident A was "Always incontinent [lacking control]" of bowel and of the urinary bladder.During an interview with a Home Health and Hospice Registered Nurse (HHN) on 10/3/13, at 8:30 AM, she indicated she had cared for Resident A before and after her 5-day stay in the facility. The HHN stated she had seen Resident A twice prior to her admission to the facility, on 8/1/13 and on 8/8/13 (the day before admission). The HHN indicated Resident A had a single wound on her knee and "no other wounds" prior to admission to the facility.The HHN indicated she saw Resident A again a third time, in her home on 8/14/13, the day after she was discharged from the facility. The HHN indicated at that time, Resident A had two (2) new, deep tissue injuries that were dark purple in color, to her lower back and to her heel, which were not present prior to Resident A's 5-day stay at the facility.During a review of the clinical record on 10/3/13, the document titled "Hospice RN Non Billable Visit", dated 8/13/13, written by the HHN, read she had informed FM 1 that Resident A "has new deep tissue injuries on her left heel and on her buttocks. [FM 1] is extremely upset by this information and becomes tearful stating 'I knew I shouldn't have sent her there.' [FM1] States that she visited patient daily in [facility] and was told that patient would not eat, but she was able to feed patient at each of her visits with patient there." During an interview with the facility Nurse Manager (NM) on 10/4/13, at 1:25 PM, she indicated since Resident A was a hospice resident, a specialized, "lateral rotation air flow mattress" would not have been provided by the hospital, but by the home health & hospice agency. The NM indicated even though the facility had a supply of such mattresses on the premises, Resident A could not use them, and indicated her mattress would have had to come from the hospice agency due to "payment issues." During an interview with the facility Certified Wound Specialist (CWS), who was also a Registered Nurse, on 10/4/13, at 1:55 PM, she indicated she had a total of four (4) such "lateral rotation air flow mattresses" available in the facility. The CWS indicated Resident A was not provided with one of the four mattresses that were available in the facility. The CWS also indicated that since Resident A was classified as a hospice resident, the mattress would have to have come from the home health and hospice agency, not from the hospital. The CWS also indicated she had seen Resident A on 8/12/13, and recalled her sitting on her heel while in bed.During a concurrent record review and interview with the NM and CWS on 10/4/13, at 2:05 PM, the NM indicated Resident A was on a lateral rotation air flow mattress at the facility on 8/12/13. The NM was not able to find documentation that Resident A was on such a mattress prior to that date. Both the NM and CWS were not able to find any documentation Resident A had any other wounds at admission to the facility, other than a minor scab on her knee.The NM also indicated that as soon as a resident is admitted to the facility, a "Mini-Care Plan" is completed "immediately... so we know what to do for the resident as soon as they are admitted." The NM was not able to find any information on the Mini-Care Plan addressing Resident A's skin condition, risk for skin breakdown, or contractures.During an interview with FM 1 on 10/8/13 at 1 PM, she stated Resident A had passed away at home on 9/27/13, forty-five (45) days after discharge from the facility. FM 1 stated she visited Resident A at the facility on 8/9/13, the first day of her admission, and had noticed she wasn't on a special air mattress, like the one she had at home. FM 1 stated that while at home, Resident A was provided a special air mattress that "revolves, it deflates and blows up certain sections at a time. It's to keep people from getting bed sores. [In addition to the special mattress], I turned her all the time, every two hours [while at home]." FM 1 indicated during her visit on 8/9/13, she asked facility staff 'where is her air mattress?' and was told 'We don't have any.' FM 1 indicated the special mattress did arrive finally on Monday, 8/12/13. FM 1 stated "Until then, she had a regular mattress. They ordered one, but it didn't arrive until Monday." During an interview with the Home Health and Hospice agency Manager (HHM) on 10/8/13 at 1:45 PM, she indicated the agency continued to assist in caring for Resident A after discharge from the facility. The HHM indicated Resident A had been a patient of the agency since January 2013, and died on 9/27/13. The HHM stated the specialized, "lateral rotation air mattress" was ordered for Resident A on Friday, 8/9/13. The HHM stated the mattress did not arrive in the facility for Resident A until Monday, 8/12/13, or the morning of the fourth day of admission to the facility. The HHM indicated the reason for the delay was the company they get the mattresses from stated they never got, or lost, the order from Friday, 8/9/13. The HHM indicated that on Monday, 8/12/13, when it was noted Resident A had never received the mattress, the company was contacted again, and delivered the lateral rotation air mattress that same day.The HHM indicated that for this type of hospice resident, who is admitted to a facility for short stay respite care, the agency takes a copy of their own care plan, and adds it to the facility's clinical record, and then coordinates care with the facility staff.During a review of the clinical record, the document titled "RRH Home Health", dated 8/7/13, under "Plans", there are no entries regarding Resident A's significant risk of skin breakdown secondary to her age, disease processes, poor nutritional status, inability to reposition herself, and bowel & urinary bladder incontinence.During an interview with the NM on 10/9/13, at 5 PM, she indicated hospice staff didn't arrive in the facility until Day 4 of Resident A's stay. The NM stated there was no Hospice documentation in the clinical record for the dates of 8/9/13, 8/10/13, or 8/11/13, "because they weren't here those days.... [they] don't come on weekends. We [the facility] didn't have a care plan in place for her, on what we're doing for her in this facility, other than some routine things, things we'd normally be doing. But much of their care plan covers areas of care in the home. I looked and couldn't find anything else. The NM indicated there was no care plan for Resident A from the facility that addressed her skin care issues.During an interview with a Home Health and Hospice agency Certified Nursing Assistant (HHA) on 10/9/13, at 3:30 PM, she stated she knew and remembered Resident A well. The HHA indicated she had cared for Resident A for about eight months, since January 2013, coming to her home two to five times a week, with five times a week occurring more recently. The HHA indicated her duties included feeding her breakfast, bathing, oral care, and changing the linens & clothing. The HHA stated prior to entry to the facility, Resident A only had a sore on her knee, but then "she went to [the facility] and became a huge mess. She came home with huge sores on her." The HHA indicated she went to the facility for the first time on 8/12/13, Resident A's fourth day of her stay, to bathe her and became upset at what she observed. The HHA indicated she told her supervisor (HHM) what she observed, who then directed her to put her observations in writing. The document from the HHA, dated 8/16/13, and addressed to the Home Health and Hospice agency's Medical Director (HHP), read in part, the following: "Re: Incident involving [Resident A] This is a written report about things I have observed while the patient was staying in the [facility] to give the family a week off. On Monday, [8/12/13] I... went to the [facility] to bathe [Resident A]. Pt. was visibly altered, sleepy and lethargic... not her usual state of being. She was not on the standard air mattress that our Hospice patients get. When we undressed the patient for her shower... we observed an angry red, inflamed area that reached from both groins all the way up to the top of her crack and spread side to side about 2 inches. On her butt area she had a deep purple colored like a blister approximately 2 inches in diameter. Also her severely bent left leg had her foot in her crotch which was also angry red and inflamed that reached from her heel to her calf area. To me, it looked like she had been left in her own poop and pee and her skin burned.At this time I went to get [RN 1]. As I was telling her about my findings, she told me, 'The patient came in with that wound.' I told her 'The wound on her left knee, yes, but not this.' And, I showed her the groins, the butt, and leg of the patient. We finished the shower... several nurses including [the CWS] were inspecting the sores. Throughout this whole time, [Resident A] was out of it. At this time, we knew we had to report it to [a supervisor].I believe [Resident A] had not eaten for a couple of days. I asked if I could go back and feed her. [She] ate about 2/3 of her pureed oatmeal. During the meal, the nurse came in to administer... Haldol [a psychotropic medication that effects mood, behavior & alters thought processes]. I asked if she could wait until I finished feeding the patient because I felt it might make her more out of it than she was. At that point, the patient opened her mouth very wide, and the charge [nurse] said she was choking (she wasn't choking) and I stopped, none the less, and sat with her and talked to her for five minutes until I knew she was okay. Then the nurse gave her Haldol. I felt it was necessary to write all this down while it was fresh in my mind." During a review of the clinical record, the document titled "Hospice Registered Nurse Routine Visit", dated 8/12/13, was reviewed. It read "Noted a deep tissue [injury] on patient's coccyx and also on patient's right heel. Right leg noted to be retracted up against patient's peri region causing friction and pressure, placed a small folded pillow case between both places to reduce pressure." During a review of the clinical record, the document titled "Measurements Report", dated 8/9/13 through 8/13/13, indicated Resident A was served thirteen (13) meals while at the facility. The word "refused" is documented next to every meal entry, except for two: 75% of lunch, and 25% of dinner, both on 8/10/13. During an interview with HHA on 8/23/13, at 11 AM, she indicated normally at home, she placed a pillow between her foot and perineal area, to reduce pressure. The HHA indicated she saw "nothing like that" during her visit at the facility on 8/12/13, and added she didn't think there was any repositioning with pillows occurring.The HHA also indicated the facility staff told her Resident A couldn't swallow. The HHA stated "I said 'What are you talking about?' I feed her breakfast every morning, five times a week. And she ate fine after she came home. So, I was like, 'what do you mean, she can't eat?' "During an interview with FM 1 on 10/24/13, at 11:30 AM, she stated the HHA and herself always fed Resident A with spoon and straw, never a syringe, or 'by force'. FM 1 stated the facility staff had often told her Resident A "wasn't hungry". FM 1 indicated neither HHA nor herself had any difficulties feeding her by spoon. FM 1 indicated she didn't want to place Resident A in the facility, but was repeatedly assured by facility and home health & hospice agency staff that she "will be fine" there. FM 1 indicated she, with the assistance of HHA, had kept Resident A clean and free of wounds for the past year, however, after admission the facility, she experienced multiple deep tissue injuries after just three days.The facility neglected to provide care necessary such as frequent skin assessment, nutrition, hydration, and assisted devices to maintain her skin integrity. These wounds had caused additional pain and suffering to her end of life quality of care. This failures had presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120000323 |
Ridgecrest Regional Hospital Transitional Care and Rehabilitation Unit D/P |
120010662 |
A |
06-May-14 |
I2VI11 |
7450 |
72311. Nursing Service -General (a)Nursing service shall include, but not be limited to, the following: (3) Notifying the attending physician promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. Based on interview and record review, the facility nursing staff failed to notify one patient's (Patient 1) attending physician (PHY A) when the patient exhibited productive cough and elevated body temperature for at least seven days, from 11/8/13 to 11/16/13. This contributed to Patient 1's condition worsening, ultimately resulting in a transfer to an Emergency Department (ED), and subsequent admission into an acute hospital with a diagnosis of pneumonia.Findings: Patient 1, a 93-year old male was diagnosed of fracture of lower extremities, below knee amputation of one leg, hypertension, benign prostate hypertrophy, muscle weakness, and cognitive impairment. On 11/6/13, the patient began having a cough. His physician (PHY A) was notified that day, and ordered cough syrup. No further updates of his condition to the physician were documented. Patient 1's condition worsened over the next several days, with elevated body temperatures (measured in degrees Fahrenheit, or øF), weakness, persisting cough, and chest congestion. On 11/17/13, Patient 1 was noted with pus (a thick fluid formed in response to an infectious process) draining from both ears, and responded to staff only with moans. On 11/17/13, the facility staff finally notified the patient's physician of the pus-like discharge. His physician ordered to send Patient 1 to a nearby ED, where he was diagnosed with pneumonia and was admitted for two days for intravenous (IV, within the vein) antibiotics. During a review of the clinical record for Patient 1, the document titled "Record of Admission" was noted. It indicated Patient 1 was admitted to the facility on 10/13/12, at the age of 92. The Minimum Data Set (MDS, an assessment tool that is completed for every patient no less frequently than every three (3) months), dated 10/20/13, indicated Patient 1 could make himself understood, and usually could understand others. He needed extensive assistance moving himself about in bed, transferring from his bed to a wheelchair, with hygiene, dressing, toileting, and bathing.During a review of Patient 1's clinical record, it indicated that, on 11/5/13, a fax was sent to the patient's attending physician (PHY A) which read: "RE: coughing...having non- productive cough, dry cough. May we have an order for it? No fever noted, lung sounds no wheezing, no crackles." The fax indicated PHY A ordered a cough syrup to be given every six (6) hours as needed for the next five (5) days. The next day, on 11/6/13, the document titled "Nursing Notes" read at 9:50 PM, a telephone order came from an un-named physician, for a different cough syrup, and to be given for Patient 1's "coughing spells & nasally congested," every four (4) hours as needed for the next five (5) days, ending on 11/11/13. The following are excerpts from the documents titled "Nursing Notes" from the next several days: 11/8/13, at 7:30 PM: "Spend all day in bed. Cough with gray mucous discharge observed. Will continue to monitor." 11/9/13, at 2 AM: "(Temperature is) 99.0ø (F)... has 3 episodes of coughing." 11/9/13, at 2 PM: "(Temperature is) 100.6ø (F), (Heart Rate is) 100 (beats per minute, or BPM, [Respiratory Rate is) 22, (Blood Pressure is) 160/72...Cold measures initiated. Patient lying in bed with a sheet over him only. Bed bath with lukewarm water given to help bring temperature down. (Prescribed pain medicine) given for generalized body pain. Will continue to monitor." 11/9/13, between 3 PM and 11 PM: "(Temperature is) 98.9ø (F), (Heart Rate is) 96...monitored for fever...given a cold compress to reduce fever...rested all evening." 11/9/13, at 9 AM: "(Temperature is) 99.5ø (F)...monitored for fever. No signs of increased temperature during shift." 11/11/13, between 7 AM and 3 PM: "Patient resting in bed. Will continue to monitor." 11/12/13, at 2 PM: "...patient was feeling weak today - was having a hard time standing up - even with weight bearing assistance. Patient still has a cough and congestions. Will monitor." There were no more entries in the "Nursing Notes" for Patient 1 for the next four (4) days; 11/13/13, 11/14/13, 11/15/13, and 11/16/13. There were no entries anywhere in the clinical record indicating PHY A had been notified of any of Patient 1's changes of condition (increased temperature & fever, productive cough, weakness, lethargy) from the dates of 11/7/13 through 11/16/13. On 11/17/13, at 10 AM, the following "Nursing Note" read: "...patient (Patient 1) was slow to respond. Only responded with moan. Would not open eyes or answer questions. ALOC (Altered Level of Consciousness). CNA [Certified Nursing Assistant] reported fluid draining from ears. Mucous of honey consistency - yellow color noted. (Physician) notified at 11:40 AM, ordered to send to (local GACH's ED) for observation and evaluation. Patient to [ED] at 12:20 PM by ambulance. VS 96.6ø (F), 91. 02 sat[uration, a measurement of how much oxygen is bound to red blood cells, usually above 96%] 91%. CNA staff also reported patient's chest congestion 'was worse', lung sounds rhonchi, crackly [terms used to describe sound of secretions in the airways], in all four quad[rant]s." During an interview with Licensed Vocational Nurse 1 (LVN 1), on 2/20/14, at 10:03 AM, she stated Patient 1's physician, or the on-call physician, should have been notified if he had a temperature of 100.6øF. LVN 1 stated the facility staff should "Call MD, put (Patient 1) on alert charting." During an interview with Licensed Vocational Nurse 2 on 2/20/14, at 10:05 AM, she indicated if any patient had a temperature of 100.6øF; a physician should be called "immediately." During an interview with Licensed Vocational Nurse 3 on 2/20/14, at 10:10 AM, she indicated if a patient had a temperature of 100.6øF, the nursing staff should start cooling measures, and call the MD. LVN 3 stated, "I don't know why a physician wasn't called" for Patient 1's change of condition.During a concurrent record review and interview with the Director of Nursing (DON) and LVN 1, on 2/20/14, at 10:15 AM, Patient 1's clinical record was reviewed. The DON stated "Yes, we have to call a physician for a temperature of 100.6øF." Neither the DON nor LVN 1 could find any documentation in the clinical record of any physician notification for his changes of condition between 11/6/14 and 11/17/14.The document from the acute hospital's ED, titled "Emergency Room Triage Report," dated 11/17/13, at 12:59 AM, read, Patient 1, "presents to the ED unkempt, with copious amounts of green purulent (containing 'pus'), drainage to left ear, bilateral eyes with dried green drainage, pt. with moist rattily cough suctioned for copious amounts of green sputum (thick mucus that is normally able to be coughed up from the lower airways)."The document titled "Emergency Physician Record," indicated Patient 1 had "pneumonia" and he was admitted to the hospital on 11/17/13, at 2:20 PM for further treatment.The facility staff failed to notify Patient 1's attending physician when he exhibited change of medical condition had presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120000323 |
Ridgecrest Regional Hospital Transitional Care and Rehabilitation Unit D/P |
120010681 |
A |
06-May-14 |
INFC11 |
15536 |
CFR 483.13 (b) - (F223) - Abuse - The Resident has the right to free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility failed to keep patients in the facility free from physical and verbal abuse, when one patient (Z), who is able to move independently through the hallways, struck with his fist and caused significant injury to one patient's (A) face, and, intentionally grabbed with his hands and tipped over the wheelchair of a second patient (B) while she was in it, knocking her over onto the floor. Prior to these assaults, the facility failed to intervene, and protect other residents from Patient Z's harm.These deficient practices constitute a Class "A" citation.Findings:A letter from the facility to the Department, written by the Director of Nursing (DON) and dated 11/16/13, read:"Patient [Z] struck another patient [A, a 92-year old female] on the face without provocation," and, "[Patient Z is] able to propel his wheelchair", and "[Patient A] sustained a small cut on her left forehead, small bruising on her left chin. She was sent to the ER (emergency room) for further evaluation of condition." The letter also read, "[Patient Z] is redirected away from other patients and medicated to keep him calm." The letter ended with "In conclusion, the incident was unprovoked and attributed to [Patient Z's] behavior manifested by striking out without provocation."During an observation on 11/27/13, at 12:55 PM, Patient Z was observed in his room. He was seated in his wheelchair, and immediately upon seeing the surveyor, Patient Z started yelling out in Spanish, and moving his wheelchair about in his room, and appeared agitated.There were not any staff in the room, or nearby in the hallway, during this observation.During an interview with Licensed Vocational Nurse (LVN) 1 on 11/27/13, at 1 PM, she indicated Patient Z usually stays in his room, but does come out in his wheelchair into the hallway, but when he does, "we monitor him."During an interview with the DON on 11/27/13, at 1:20 PM, she indicated the interventions the facility had been taking to keep patients safe from Patient Z's further assaults was, "We monitor and redirect." She indicated there had not been a special appointment made for psychiatric counseling, since "He (Psychiatrist) comes in monthly anyway."During an interview with Certified Nursing Assistant (CNA) 1 on 11/27/13, at 1:05 PM, she stated she was an eyewitness to the assault on Patient A. CNA 1 stated on 11/16/13, in the hallway, near the nursing station, Patient A waved her hand toward Patient Z, like saying 'hello'. CNA 1 indicated Patient Z then started to yell, and hit her in the face with an open hand twice, then with a closed fist once. CNA 1 indicated this happened quickly, and "before I could separate them." CNA 1 stated Patient A "was bleeding a lot. I don't think [Patient Z] should be here, he's a danger to the patients. We made his room a private one for him. He's attacked some staff before."During a review of the clinical record of Patient Z, the document titled "Record Of Admission" indicated he was admitted to the facility on 6/10/13. His diagnosis included encephalopathy (a broad category of brain disorders, Patient Z's is "unspecified"), and altered mental status. Patient Z is 56 years old.The document titled "Psychiatry Initial Evaluation", dated 7/14/13, was reviewed. Written by a "Board Certified Psychiatric Physician Assistant" (PA), it contained, in part, the following: "[Patient Z] has hit several of the staff aids multiple times requiring two of them to have to go to the hospital for their injuries. It is unclear to me at this time why the facility is continuing to keep the patient here as he clearly is a risk to himself and to the staff. Past Medical History [is] significant for dementia with psychosis... Recommendations: ...placement in a facility more appropriate for this patient considering his severe aggression... the patient should likely be transferred to a locked facility that can deal with his aggressive behavior more appropriately."The document titled "Gero-Psychiatry Progress Note", dated 9/29/13, and written by the PA, was reviewed. It read, in part, "The patient continues to have severe behavioral disturbances. At the current staffing level, the facility is "unable to provide" a safe environment for the patient's significant behavioral problems at this time. We are attempting to locate a facility... the patient's primary care physician does understand and does agree for the patient to leave the facility and be admitted to another skilled nursing facility with more appropriate psychiatric care available. The facility reports that the patient acts out on a regular basis and displays behaviors that are beyond their ability to control."However, the document titled "Medication Management/Behavior Evaluation Visit", dated 11/23/13 (seven days after the assault on Patient A), was reviewed. Written by the PA, it read "Per staff, no significant behavior changes are reported. Not physically aggressive. Recommendations: Continue current orders and plan of care."The document titled "Physician's Orders" (PO) indicated he had an order, dated 6/10/13, to receive the drug "Ativan" (an anti-anxiety agent) routinely twice a day, by mouth, for anxiety as manifested by "striking out" and "inability to sit still." The PO also indicated he was to receive Ativan by mouth on an "as needed" basis, either by mouth (ordered 6/10/13, for the same manifestations), or by injection (ordered 7/3/13, for the added behaviors of "hitting, kicking, punching, and scratching, if he refuses the oral medications").The document titled "Medication Administration Record" (MAR) was reviewed, it indicated Patient Z did not receive a single "as needed" oral dose of Ativan during 11/2013, and received a single dose of injectable Ativan on 11/17/13, the day after the assault on Patient A.The PO also indicated Patient Z had an order for the anti-psychotic drug "Seroquel" to be given every night, by mouth, for "psychosis manifested by outburst anger." Another order for Seroquel, dated 8/25/13, indicated he was to receive a smaller dose once daily, by mouth, for "psychosis manifested by yelling, screaming, hitting."The PO beginning 11/1/13 were reviewed, and it contained a "Previous Month Behavior Tally" for the manifested behaviors requiring the use of Ativan and Seroquel. The tally covering the month of 10/2013 included: "striking out" a total of 41 times, "hitting" a total of 10 times, "outburst anger" a total of 107 times, "screaming" a total of 71 times, and "yelling" a total of 82 times.The document titled "Resists Care Plan of Care", dated 7/8/13, read Patient Z "Resists care as evidenced by loud, verbal resistance (yelling), physically refusing (hitting, kicking, punching, pulling off colostomy)." On 11/16/13, it was added "Anger outburst without provocation, strikes at others." The intervention for this was to "Redirect patient away for other patients." The single goal for these identified behaviors was for Patient Z to take "at least one shower every week."The documents titled "Licensed Nurse Weekly Summary" were reviewed, and are a summary of Patient Z's last seven days in the facility, done on a weekly basis. The Summaries dated 10/22/13, 10/15/13, 10/8/13, 9/20/13, 8/27/13, and 7/7/13 all documented Patient Z had been "physically abusive" at some point during those weeks.The document titled "Nursing Notes", dated 11/16/13, at 12:30 PM, read: "[Patient Z] attacked a chair bound patient... struck [Patient A] 3 times on the face, leaving... a laceration to forehead and bruise on chin on left side. The incident occurred without provocation. Will continue to monitor."During a review of the clinical record for Patient A, the report from an acute care hospital's emergency room, dated 11/16/13, indicated she had been diagnosed with a "sprained neck", and was directed to wear a "soft neck collar." Patient A was not interviewed due to her cognitive deficits.A second letter from the facility, to the Department and written by the DON and dated 12/2/13, indicated Patient Z "caused another Patient [B] to fall off wheel chair." This occurred on 11/29/13, or 13 days after the incident with Patient A. The letter indicated Patient Z, "who is able to propel his wheelchair... was observed approaching another [86 year old female] patient, staff attempted to move him away from the other patient, by the time staff got to the patient, he had lifted the other patient's wheelchair resulting to the other patient falling off of her wheel chair. [Patient Z] was observed wheeling his wheelchair towards [Patient B]. Staff tried to stop [him] but he managed to grab and lifted [her] wheelchair handle... [she] fell off of her wheelchair landing on the floor on her knees. Body check was done... no injury noted. At this time, staff continues to redirect [Patient Z] away from other patients. The Social Services Director [SSD] is in the process of looking for a gero-psyche facility [a specialized facility that treats psychiatric disorders in the elderly] to place [Patient Z]."During an observation of Patient Z on 12/3/13, at 12:55 PM, he was in his room, seated in his wheelchair, moving it back and forth several inches with his hands on the wheels, in what appeared to be an agitated state. There was no staff in the room with him, or near the entrance to his room. The door was wide open. During the next two hours, numerous patients were observed moving about in the hallway outside his room. Often there was no staff presence in the hallway outside his room for several minutes at a time.During a review of the clinical record for Patient B, the document titled "Nursing Notes" dated 11/29/13, was reviewed. It read "Patient was in hallway and another patient bumped into her W/C (wheelchair) and became angry and tipped her W/C forward. Range of Motion intact X4 [extremities], Neuro[-logical function] Within Normal Limits, no complaints of pain. Will continue to monitor." Patient B was not interviewed, because of her cognitive deficits.During an interview with the DON on 12/3/13, at 1 PM, she was asked what interventions are in place to keep other patients safe from assault, since Patient Z had assaulted two patients in 13 days. The DON stated "I don't have the staff for a one-on-one. I have discussed this with the Administrator."During an interview with a Housekeeper (HSK) on 12/3/13, at 1:30 PM, she indicated she was fluent in Spanish, and speaks Spanish to Patient Z. She stated Patient Z had threatened in Spanish "to kill" her, on 11/28/13, and she was afraid of him, afraid he would assault her.During an interview with a facility visitor (VIS) on 12/3/13, at 2:05 PM, he stated he had been at the facility visiting a friend twice a day for several months. The VIS indicated he had seen Patient Z attempt to use his fist to hit his friend, who is a patient at the facility. The VIS indicated he felt the patients are "at risk, in danger of being hurt. I fear he's really going to hurt someone."During an interview with LVN 2 on 12/3/13, at 2:55 PM, she indicated she assessed Patient B after Patient Z assaulted her. LVN 2 stated she did not know why Patient Z had not been placed on one-to-one monitoring. LVN 2 stated, "I'm not scared of him, but I imagine there are many patients who are."During an interview with CNA 2 on 12/3/13, at 3 PM, she indicated Patient Z can come out of his room independently. She indicated he becomes agitated at least once per day, and when this happens, nothing can calm him except "maybe time."During an interview with CNA 3 on 12/3/13, at 3:05 PM, she indicated she was fluent in Spanish and English. She indicated she had worked with Patient Z ever since he was admitted into the facility. CNA 3 indicated she frequently speaks Spanish to Patient Z since he speaks Spanish, but it does not really make any difference, because "he still gets mad and angry, responds aggressively. I explain things to him in Spanish, he still gets aggressive. He's hit me before."During an interview with CNA 4 on 12/3/13, at 3:07 PM, she indicated Patient Z can walk independently, and does not need his wheelchair to come out of his room. CNA 4 indicated she was assigned to care for Patient Z that day, and there were no interventions in place to keep him from coming out of his room, or to monitor him closely. CNA 4 stated "We don't do one-to-one care here, I don't know why. He's really aggressive, he swings at me frequently. I know he's assaulted other patients."During an interview with CNA 5 on 12/3/13, at 3:10 PM, she indicated Patient Z had struck her before, and "he can hit really hard. I don't know why he's not on a one-to-one. He does go to the dining room [an area frequented by many other patients] sometimes."During an interview with the LVN and Minimum Data Set (an assessment tool) Nurse 2 (MDS 2) on 12/3/13, at 3:15 PM, she indicated she participated in the facility's interdisciplinary meetings (IDT) regarding Patient Z. MDS 2 indicated a one-on-one staffing ratio "isn't something we do here. We have discussed him in IDT, it's not been brought up. I know Social Services is trying to find placement for him [in another facility], and is having difficulty with that." MDS 2 was not aware of any other interventions in place to prevent assaults to other patients.During an interview with the SSD, on 12/3/13, at 3:17 PM, she indicated she was looking for another facility that would accept Patient Z, a facility better suited to care for him. The SSD indicated there were problems with placement because of insurance issues, and because of his colostomy (a surgical intervention resulting with the patient defecating into a pouch, usually attached to an opening on the abdomen). The SSD was asked to provide documentation of these efforts, and she directed the surveyor to her "Social Service Notes."During a review of the clinical record for Patient Z, the documents titled "Social Service Notes" were reviewed. The most recent entry regarding efforts to place Patient Z in another, more appropriate, facility was 10/2/13 (two months ago).During an interview with the DON on 12/2/13, at 3:20 PM, she indicated the facility has been trying to find alternate placement for Patient Z. The DON stated Patient Z "doesn't really need a one-to-one, because he's in his room, quiet." The DON indicated if his behaviors increase, "maybe we'll get a Spanish-speaking person to talk with him, but not a CNA. He doesn't require a medical person, but maybe a Spanish-speaking sitter to sit with him." When informed two Spanish - speaking staff, upon interview, stated that speaking Spanish to Patient Z appeared to have no calming effect, the DON had no comment.The facility was aware Patient Z posed a danger to other patients in the community but did not take any actions to ensure their safety. Two patients, Patient A and B, were victims of such inaction. Therefore, the facility had placed its patients and staff at risk for continuous assaultive behavior from Patient Z.Patient A, a 92 year-old female, suffered actual harm with lacerations to her face and a sprained neck. Patient B, an 86 year-old female, experienced actual harm when she was thrown from her wheelchair to the floor by Patient Z. Such failure presented either imminent danger that death or serious harm would result, or a substantial probability that death or serious physical harm would result. |
| 120000323 |
Ridgecrest Regional Hospital Transitional Care and Rehabilitation Unit D/P |
120010682 |
B |
06-May-14 |
INFC11 |
6613 |
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.The facility delayed in reporting two (2) separate episodes of abuse to the Department within required timeframes. These delays in reporting to the required agencies constitute a Class "B" Citation.Based on record review and interview, the facility failed to report to the Department two separate episodes of abuse within the time frames required by law, and their own policy and procedure. Episode 1, which involved serious bodily injury, was not reported to the Department for approximately 27 hours; Episode 2 was not reported to the Department for approximately 76 hours. Per the Elder Justice Act for Skilled Nursing Facilities, "Events that result in serious bodily injury shall reported immediately, no later than 2 (two) hours after forming the suspicion, and all other reports within 24-hours... to the Licensing and Certification Program of the California Department of Public Health [the Department]." Findings:1. A letter from the facility to the Department, written by the Director of Nursing (DON) and dated 11/16/13, read:"Resident [Z] struck another resident [A, a 92-year old female] on the face without provocation", and, "[Resident Z] is able to propel his wheelchair", and "[Resident A] sustained a small cut on her left forehead, small bruising on her left chin. She was sent to the ER (emergency room) for further evaluation of condition." The letter ended with "In conclusion, the incident was unprovoked and attributed to [Resident Z's] behavior manifested by striking out without provocation."During an interview with Certified Nursing Assistant (CNA) 1 on 11/27/13, at 1:05 PM, she stated she was an eyewitness to the assault on Resident A. CNA 1 stated on 11/16/13, in the hallway, near the nursing station, Resident A waved her hand toward Resident Z, like saying 'hello'. CNA 1 indicated Resident Z then started to yell, and hit her in the face with an open hand twice, then with a closed fist once. CNA 1 indicated this happened quickly, and "before I could separate them." CNA 1 stated Resident A "was bleeding a lot. I don't think [Resident Z] should be here, he's a danger to the residents. We made his room a private one for him. He's attacked some staff before."The document titled "Nursing Notes", dated 11/16/13, at 12:30 PM, read "[Resident Z] attacked a chair bound resident... struck [Resident A] 3 times on the face leaving... a laceration to forehead and bruise on chin on left side. The incident occurred without provocation. Will continue to monitor."During a review of the clinical record for Resident A, the report from an acute care hospital's ER, dated 11/16/13, indicated she had been diagnosed with a "sprained neck", and was directed to wear a "soft neck collar." Resident A was not interviewed due to her cognitive deficits.The facility reported this incident occurring on 11/16/13 to the Department on 11/17/13, at 3:30 PM, approximately 27 hours later. It should have been reported within two hours, since the abuse caused serious bodily injury to a 92-year old woman.2. A second letter from the facility, to the Department and written by the DON and dated 12/2/13, indicated Resident Z "caused another Resident [B] to fall off wheel chair." This occurred on 11/29/13, or 13 days after the incident with Resident A. The letter indicated Resident Z, "who is able to propel his wheelchair... was observed approaching another [86 year old female] resident, staff attempted to move him away from the other resident, by the time staff got to the resident, he had lifted the other resident's wheel chair resulting to the other resident falling off of her wheel chair. [Resident Z] was observed wheeling his wheelchair towards [Resident B]. Staff tried to stop [him] but he managed to grab and lifted [her] wheelchair handle... [she] fell off of her wheelchair landing on the floor on her knees. Body check was done... no injury noted."During a review of the clinical record for Resident B, the document titled "Nursing Notes" dated 11/29/13, was reviewed. It read that at 11 AM, "Resident was in hallway and another resident bumped into her W/C (wheelchair) and became angry and tipped her W/C forward. Range of Motion intact X4 [times four extremities], Neuro[-logical function] Within Normal Limits, no complaints of pain. Will continue to monitor." Resident B was not interviewed, because of her cognitive deficits.The facility reported this incident occurring on 11/29/13, to the Department on 12/2/13, at 3:20 PM, or approximately 76 hours later. It should have been reported to the Department within 24 hours.During an interview with the Director of Nursing (DON) on 12/2/13, at 3:20 PM, she was asked why the two episodes of abuse occurring on 11/16/13 and 11/29/13 were not reported within the required time frames. Regarding the episode on 11/16/13, the DON indicated she was not aware of the Elder Justice Act, and episodes of abuse resulting in serious bodily injury were to be reported to the Department within 2 hours. Regarding the episode on 11/29/13, the DON explained that it was the day after Thanksgiving, and she was out of the facility, but had received a telephone call from staff on duty informing her about the episode. The DON indicated her plan was to come in to the facility that day and report it to the Department, "but I couldn't make it in." When asked why she couldn't call the facility and instruct on-duty staff to report it to the Department, the DON had no comment.The facility policy and procedure titled "Elder Abuse Investigation and Reporting Policy" dated 11/1/03, was reviewed. It read, in part, the following:"The Administrator of the facility shall report all "alleged" or "suspected" abuse of a resident to the [Department] immediately, or within 24 hours.""Upon hire, new employees shall be informed of the obligation to report alleged violations... Each associate shall receive training no less frequently than annually on the requirements of the facility's policies and procedures regarding alleged violations and the requirements of state and federal law."The policy and procedure, over ten years old, contained no information regarding the Elder Justice Act requirements for Skilled Nursing Facilities.This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 630013665 |
Ridgecrest Regional Transitional Care and Rehabilitation Unit |
120011861 |
A |
28-Dec-15 |
FY6211 |
7285 |
F323 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Based on observation, interview, and record review, the facility failed to use adequate mechanical lift and personnel required to transfer one of one sampled resident (1) from chair to bed when Certified Nursing Assistant (CNA) 1 decided to transfer Resident 1 alone using the wrong mechanical lift, Sara Lift (an assistive device used on those residents who have difficulties getting up into a standing position). The facility had a written care plan for Resident 1 to be transferred only by a Marisa Lift (a mechanical lift using a sling to transfer patients who are unable to use their legs. It requires two staff to assist residents). This failure resulted in Resident 1's falling from the wrong lift and fracturing her left shoulder. An unannounced visit was made to the facility on 10/22/15 at 8 AM, to investigate a resident's fall with injury. Resident 1 was a 76 year old female with a history of stroke (the sudden death of brain cells in a localized area due to inadequate blood flow) with muscle wasting (a decrease in the mass of the muscle), left sided weakness, convulsions (contortion of the body caused by violent, involuntary muscular contractions of the extremities, trunk, and head), and hypertension (elevated blood pressure).During a concurrent observation and interview with Resident 1, on 10/22/15, at 8:47 AM, in Resident 1's room, Resident 1 was sitting in her wheelchair. Resident 1 had left sided weakness with left arm and left leg weakness. Resident 1's left arm was flaccid (hanging loosely) and her left foot had foot drop (dropping of the front of the foot due to weakness or paralysis of the upper muscles of the lower leg). Resident 1 stated, "I broke my left shoulder." When asked how it happened, she stated, "When I was getting ready to go to bed, she [Certified Nursing Assistant-CNA 1] went to turn me at the side of the bed. I heard my right leg crack." When asked what device CNA 1 use to help her transfer, she stated, "She made me stand up. My body did not turn as fast as the machine did; I slipped through the machine to the floor."During an interview with Registered Nurse (RN) 1, on 10/22/15, at 9 AM, she stated, "[CNA 1] used the Sara lift. She [CNA 1] was supposed to use a Marisa lift." RN 1 stated, "[Resident 1] was lying on her back, when she slid off, I'm guessing she might have hit her left hand on the ground." When asked how Resident 1 was supposed to be transferred, she stated, "[CNA 1] supposed to use Marissa lift for [Resident 1] and supposed to be 2 persons assist."During a review of the clinical record for Resident 1, the "CNA Mini Care Plan", undated, indicated, "Lift used: Marissa Lift." The "Fall Risk Evaluation", dated 8/11/15, indicated a score of 14 [total score of 10 or above represents high risk]. The "At Risk for Fall Care Plan", dated 5/8/15, indicated, "PT [Physical Therapy] states: Marissa [lift] only." The "Functional Status", dated 7/28/15, indicated, "Transfer: Extensive assistance, two person assist." The "Nurses' Progress Note", dated 10/8/15, indicated, "Body Control Problems: History of Cerebro-Vascular Disease (disorders of the blood vessels that supply blood flow to the brain), left hemiparesis (weakness of one side of the body), contractures (deformity) bilateral (both) upper and lower extremities." The Brief Interview for Mental Status (BIMS) dated 7/28/15, indicated Resident 1 had a score of 13 which indicated she was cognitively intact. During an interview with CNA 1, on 10/22/15, at 9:35 AM, when asked what happened on 10/6/15 with Resident 1, she stated, "I could not reach for the sling underneath her back so I decided to use the Sara lift." When asked if she called for help, she stated, "No, I did not call for help, everybody was busy. I thought it will be ok to use the Sara lift." When asked if CNA 1 was aware what was in Resident 1's care plan, she stated, "Yes, I know she's supposed to use the Marissa lift and needs 2 persons assist." When asked how Resident 1 fell, she stated, "[Resident 1's] right leg bended and was about to fall so I grabbed her on her rib area and slowly lowered her on her bottom and then I laid her down to get help."During a review of the clinical record for Resident 1, the "Nursing Notes", dated 10/6/15, at 3:40 PM (post fall), indicated, "Complained of pain at the left shoulder and right leg, medicated with Norco [strong medication for pain] 10-325 mg [milligram] (1 tablet)." The "PRN [as needed] Medication Record", 10/2015, indicated Resident 1 received Hydrocodone-Acetaminophen [strong medication for pain] 10 mg-325 mg [milligram] tablet for severe pain on 10/6/15. The "Pain Flow Sheet", dated 10/6/15, at 2:45 PM, indicated, "Location of pain: left arm and right leg, Current intensity: 7/10 [intensity of pain scale where 0 means no pain and 10 means very painful], Precipitating/Aggravating factor: movement."During an interview with the Director of Nursing (DON), on 10/22/15, at 10:49 AM, she stated, "The staff did not follow the policy and procedure, I told the CNA [1] we cannot downgrade a lifting device. Resident (1) had flaccid arm."During a review of the clinical record for Resident 1, the X-ray [pictures to see the inside parts of the body] results, dated 10/11/15, indicated, "Impression: Nondisplaced impacted fracture of the left humerus at the surgical neck [broken bone on the left shoulder]."During a review of the clinical record for Resident 1, the "Nursing Notes", dated 10/12/15, at 3:30 PM, indicated, "Received X-ray results of left shoulder findings: nondisplaced fracture of the left humerus at the surgical neck [broken bone on the left shoulder] possibly related to impact from recent fall [recent fall incident happened on 10/6/15]."The facility policy and procedure titled, "Safe Lifting and Movement of Residents", dated 12/2013, indicated, "Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Safe lifting and movement of residents is part of an overall facility employee health and safety program, which: Involves employees in identifying problem areas and implementing workplace safety and injury-prevention strategies; Provides training on safety, ergonomics and proper use of equipment."The facility policy and procedure titled, "Lifting Machine, Using a Portable", dated 12/2013, indicated, "Review the resident's care plan to assess for any special needs of the resident. General Guidelines: Two (2) nursing assistants are required to perform this procedure."This deficient practice presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 630013665 |
Ridgecrest Regional Transitional Care and Rehabilitation Unit |
120012123 |
B |
21-Mar-16 |
HBYL11 |
3797 |
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 interview and record review, the facility failed to ensure one of one sampled Patient (1) was free from physical and verbal abuse from Certified Nursing Assistant (CNA) 1. This failure resulted in Patient 1 being physically and verbally abused.An unannounced visit was made to the facility on 1/25/16 at 10 AM, to investigate an allegation of Patient abuse by staff. Patient 1 was 76 year old female with a history of diabetes (high sugar levels in the blood), hypertension (high blood pressure), and muscle wasting.During a review of the clinical record for Patient 1, the nurses notes dated 1/7/16, at 2330 (11:30 PM), read, "I witnessed CNA (1) hitting Resident (Patient 1) with a pillow in the head/facial region. As CNA (1) hit (Patient 1), she told her to shut up." The Brief Interview for Mental Status [BIMS-is used to get a quick assessment of how well someone is functioning cognitively (conscious intellectual activity)] for Patient 1 indicated a score of 4 out of a possible 15 which indicated she had severe cognitive impairment.The follow-up written report of the Administrator dated 1/19/16, read, "Licensed Vocational Nurse (LVN) 1 realized that resident (Patient 1) was fully awake and sounded agitated, as she approached the door she observed CNA (1) hit resident (Patient 1) with a pillow hard enough that her head moved towards her shoulder. She heard the CNA (1) tell the resident (Patient 1) to 'shut up' she also observed that the resident (Patient 1) was under the bed covers and they were up to her chin with her arms inside and not attempting to hit out at the nursing assistant... Conclusion: ...the event did occur as witnessed. The resident (Patient 1) was not attacking the staff member her hands were under the blankets. It appears that CNA (1) when taking a pillow into the room to 'distract' any scratches that this frightened the resident (Patient 1) who had been asleep and was now startled and scared. When the resident (Patient 1) begins to cry out the staff member (CNA 1) told her to shut-up and hit her with a pillow."During an interview with the LVN 1, on 2/1/16, at 12:15 PM, she stated, "When I opened the door I can hear (Resident 1) was upset. I saw the CNA (1) hit Resident (Patient 1) with a pillow and she told her to shut up."During an interview with Registered Nurse 1, on 2/1/16, at 12:30 PM, she stated, "The LVN (1) reported to me the CNA (1) hit the Resident (Patient 1) with a pillow."The facility policy and procedure titled "Abuse Prevention Program" revised 8/2006, under Policy Interpretation and Implementation read, "1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual; Preventing Resident Abuse 2. 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...). This failure caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 120000369 |
Rosewood Health Facility |
120012211 |
B |
09-May-16 |
654411 |
5077 |
F224 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 observation, interview, and record review, the facility failed to prevent Certified Nursing Assistant (CNA) 1 from neglecting one of one sampled resident (1), which resulted in Resident 1 feeling neglected and anxious.An unannounced visit was made to the facility on 3/17/16 at 8:58 AM, to investigate an allegation of resident neglect by a Certified Nursing Assistant. Resident 1 was an 86 year old male with diagnoses including prostate (A gland within the male reproductive system that is located just below the bladder) cancer, generalized muscle weakness, benign paroxysmal vertigo (a disorder arising in the inner ear. Its symptoms are repeated episodes of a spinning sensation caused by changes in the position of the head), and obesity.The facility's "Narrative Investigative Report", dated 3/11/16, indicated CNA 1 was assigned to take care of Resident 1 around 1:30 AM on 3/10/16. Resident 1 requested CNA 1 to help him to the toilet and CNA 1 told him to "just go ahead and pee in your pants and I will clean you up after". Resident 1 then called for help after wetting himself and CNA 1 told him, "I am the only CNA on the floor". Resident 1 called again for help and asked for a urinal, CNA 1 put the urinal on Resident 1's chest and left. When Resident 1 got wet after using the urinal and asked for help at about 4 AM, CNA 1 answered the call light and promised to come but never came back. Resident 1 on was not changed until the AM shift (AM shift hours are usually 6:30 AM to 2:30 PM).During a concurrent observation and interview with Resident 1, on 3/17/16, at 9:34 AM, Resident 1 was sitting in his wheelchair with braces on both knees, alert and oriented. When asked what happened in the night shift on 3/10/16, he stated, "I rang the bell, I waited quite a while about half an hour. I said I want to use the toilet, [CNA 1] said 'just pee in your pants'. I called again and [CNA 1] handed me a urinal and said, 'Do what you can'." Resident 1 stated, "I cannot remove the tape of my brief and can't hold on to the urinal so I wet the bed." Resident 1 stated, "CNA [1] said she's the only one on duty, she said, 'I'll be back to change the bed.' But she did not come back. The next shift changed me." Resident 1 stated he felt neglected and he stated, "I was really upset, I had an anxiety attack."During a review of the clinical record for Resident 1, the "Cognitive Patterns" (the act of thinking, perceiving, and understanding), dated 3/1/16, indicated a Summary score of 15 [score of 15 means cognitively intact].The "Functional Status", dated 3/1/16, indicated, "Toilet use: Extensive assistance, one person physical assist." The "Kardex Report", dated 2/24/16, indicated, "Incontinent: Check the resident frequently throughout each shift and as required for incontinence. Wash, rinse and dry perineum (the area in front of the anus extending to the scrotum in the male). Change clothing PRN [when needed] after incontinence episodes. Observe pattern of incontinence and initiate toileting schedule if indicated. Offer urinal to [Resident 1] every 2 hours due to frequency of urination secondary to Neoplasm of Prostate [prostate cancer] with recent UTI [Urinary Tract Infection-bladder infection]."During an interview with the Occupational Therapist (OT), on 3/17/16, at 10:40 AM, she stated, "[Resident 1] talked to me that morning and reported the CNA [CNA 1] at night neglected to help him in multiple occasions with his urinal." The OT stated she filled out the grievance form and placed the paper on the Social Service desk.During an interview with CNA 2, on 3/17/16, at 1:36 PM, she stated, "[Resident 1's] wife told me about [Resident 1's] complaint about the night shift but I told her I'm not the right person to talk to so I sent her to the office."During an interview with the CNA 1, on 3/18/16, at 4:02 PM, she stated, "I was super busy, I do the whole hall and it was a heavy night." CNA 1 stated she last checked on Resident 1 at 4:30 AM and did not check on him again after that time.The facility policy and procedure titled, "Abuse and Neglect-Clinical Protocol", undated, indicated, "Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The physician and staff will help identify risk factors for abuse within the facility, example....problems related to staff knowledge, skill, or performance that might affect how residents are being cared for. Along with other staff and management, the Medical Director will help identify situations that might constitute or could be construed as neglect, for example....recurrent failure to provide incontinence care. The management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect."This failure had a direct relationship to the health, safety, or security of patients. |
| 120000369 |
Rosewood Health Facility |
120012235 |
A |
06-Jun-16 |
GCFY11 |
4647 |
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 supervise and assist one of one sampled resident (Resident 1) during personal hygiene, which resulted in Resident 1 falling and sustaining a fractured hip. An unannounced visit was made to the facility on 4/13/16, at 1:02 PM, to investigate a resident fall with a resulting fracture. Resident 1 was an 87 year old male with a history of prostate cancer (a disease in which cells in the prostate gland become abnormal and start to grow uncontrollably, forming tumors), diabetes type 2 (a chronic condition that affects the way your body metabolizes sugar), obesity, hypertension (high blood pressure), chronic atrial fibrillation (an irregular and often very fast heart rate which can cause symptoms like heart palpitations, fatigue, and shortness of breath), heart failure (Inability of the heart to pump enough blood to keep up with demands which can cause shortness of breath and swelling), generalized muscle weakness, difficulty walking, and repeated falls with a previous left hip fracture (broken hip bone). The clinical record for Resident 1 was reviewed. The care plan dated 2/23/16, indicated, "Requires assistance with activities of daily living related to; weakness due to recent illness history of fall, left hip fracture, and history of ORIF [Open Reduction Internal Fixation-Bone surgery]."The Functional Status document for Resident 1, dated 3/20/16, indicated, "Personal Hygiene: Extensive assistance, one person physical assist."The Fall Risk Assessment for Resident 1, dated 4/7/16, at 8 AM, indicated, "Fall Risk Score: 20 [score of 10 or above indicated high risk for falls]." The progress notes, dated 4/7/16, at 2:13 PM, indicated, "CNA [Certified Nursing Assistant 1] alerted nurse that resident [Resident 1] had fallen in the bathroom. Charge Nurse went to the room where resident [Resident 1] was found with right leg but in a up position [sic] and left leg bent in a sitting position. CNA [CNA 1] stated, 'I left the resident [Resident 1] in the restroom to brush his teeth, but before I left I told the student [SNA] not to leave him alone. I left the room to help someone else. I noticed the bathroom light on and found resident sitting on the floor'." The progress note, dated 4/7/16, at 6:13 PM, indicated Resident 1 sustained a hip fracture (a broken bone in the hip area) and was transported to the Emergency Department for further evaluation and treatment."The hospital "Emergency Room Report", dated 4/8/16, indicated, "Final Diagnosis: Hip fracture." During an interview with the Director of Nursing (DON), on 4/13/16, at 2 PM, she stated, "The CNA [Certified Nursing Assistant 1] stated she did leave resident [Resident 1] while brushing his teeth. [CNA 1] asked the Student Nurses' Aid [SNA-Uncertified Nurses' Aid] not to leave the resident [Resident 1]. SNA left [Resident 1]. When the CNA [CNA 1] came back, the resident [Resident 1] was on the floor." During an interview with the SNA, on 4/14/16, at 8:34 AM, she stated, "[CNA 1] told me to wait outside of the bathroom. [Resident 1] was brushing his teeth." The SNA stated another SNA called for assistance so she left Resident 1. The SNA stated she did not tell CNA 1 she was leaving Resident 1 alone in the bathroom because CNA 1 was not there. The SNA stated no one was watching Resident 1 when she left him alone in the bathroom.During an interview with the SNA Instructor, on 4/14/16, at 9:05 AM, he stated, "SNA's are not to replace Staff. They [SNA's] are only to shadow and are under supervision of a CNA or the SNA Instructor." SNA Instructor stated he was not there when SNA was watching Resident 1. During an interview with CNA 1, on 4/14/16, at 11:26 PM, she stated she put [Resident 1] in the bathroom to brush his teeth and told the SNA to watch if [Resident 1] pushes the light. CNA 1 stated she left Resident 1 to help with another resident. CNA 1 stated, "We're not supposed to ask them to do our job. They [SNA's] are supposed to just shadow us, they are not allowed to do patient care, they don't have the license." The facility policy and procedure titled, "Assessing Falls and Their Causes", dated 10/2010, indicated, "Review the resident's care plan to assess for any special needs of the resident." 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. |
| 630013665 |
Ridgecrest Regional Transitional Care and Rehabilitation Unit |
120012527 |
B |
31-Aug-16 |
HXUT11 |
10305 |
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. Based on observation, interview, and record review, the facility failed to follow its pain policy and procedure to control the pain of one of two sampled residents (Resident 1). This failure resulted in a delay of treatment and caused Resident 1 to suffer pain and negatively impacted her quality of life and well-being. An unannounced visit was made to the facility on 7/14/16 at 9:35 AM, to investigate a resident's fall with injury. Resident 1 was a 76 year old female with diagnoses of mild dementia (an intermediate stage between the expected cognitive decline of normal aging and the more-serious decline of cognitive impairment), diabetes mellitus (a condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose [sugar] in the blood cannot be absorbed into the cells of the body), coronary artery disease (Impedance or blockage of one or more arteries that supply blood to the heart), hypertension (high blood pressure), and chronic back pain. Resident 1 had a surgical history of right knee surgery, left shoulder surgery and right second and third toe amputations (surgical removal). During an interview with the Director of Nursing (DON), on 7/14/16, at 9:35 AM, she stated on 7/1/16, Resident 1 transferred herself from wheelchair to the toilet and fell on the floor. Resident 1 sustained a cut to her right eyebrow. The facility sent the resident to the local acute hospital. However, the local acute hospital transferred the resident to another out of town acute hospital due to Resident 1 needing a higher level of care. Resident 1's diagnosis was a subdural hematoma (is a collection of blood outside the brain). DON stated the resident returned to the facility on 7/3/16, and was being monitored for any change in condition. During a concurrent observation and interview with Resident 1, on 7/14/16, at 10:30 AM, in her room, she was sitting in her wheelchair and stated she fell in the bathroom (BR). She was noted with approximately one (1) inch stitched cut and a brownish/yellowish discoloration (bruise) above her right eyebrow. Resident 1 stated her right arm hurt "Do you want to see?" She pulled her right arm out of her sweater in a slow manner, grimaced and stated "Ouch." Resident 1's right arm was noted with approximately eight (8) centimeters (cm) brownish/yellowish discoloration resembling bruising to her right middle arm, again she stated "My arm really hurts." Resident 1 stated her right arm had been hurting since she fell and it was painful all the time. Resident 1 stated she told the staff regarding her pain and "Yes, it's like talking to a wall, they could care less." She stated the intensity of the pain she had on a pain scale of 0-10 (0-no pain, 10-worst pain) was seven (7). The clinical record for Resident 1 was reviewed. The Minimum Data Set (MDS- a comprehensive assessment tool) dated 5/6/16, indicated under Brief Interview for Mental Status (BIMS) for Resident 1 indicated a score of 12 (moderately impaired cognition). The "NURSING NOTES" dated 7/1/16, at 8:30 AM, indicated "Resident was calling/crying found on bathroom floor face down [sic]...c/o (complaint) rt (right) arm & rt knees pain, noted laceration to head approx (approximately) 3 inches line/cut above right eyebrow...8:40 AM, taken to ambulance via paramedics gurney." The post fall assessment for Resident 1 dated 7/1/16, at 8:40 AM, indicated Resident 1 was complaining of pain to her right arm and knee. Ten days later, the "NURSING NOTES" dated 7/11/16, at 9 PM, indicated "Physician called stating Resident's husband left a message for her saying that Resident 1 broke her arm and the facility wont [sic] give her pain medicine...I went to check on patient right arm. She said it was sore. There is a bruise to her right forearm...New order for a [sic] X-ray (XR) of patient's right forearm to be done in AM..." The "XR Forearm" result dated 7/12/16, indicated under Impression "1. Minimally-displaced fracture of the distal right ulna (wrist fracture)..." During a concurrent observation and interview with Resident 1, on 7/14/16, at 12:30 PM, in the Main dining room, she was sitting in her wheelchair with a spoon in her right hand. Resident 1 switched the spoon to her left hand in an attempt to eat her food. Resident 1 stated she had pain to her right arm and it was constant. The clinical record for Resident 1 was reviewed. The "ACTIVITIES OF DAILY LIVING (ADL) FLOW SHEET" for the month of 7/16, indicated before Resident 1's fall incident on 7/1/16, 7-3 shift, her ADL's were coded 1/1 (Supervision/Set help only) for bed mobility, transfer and toilet use. On 7/4/16, 7-3 shift, after the resident's fall incident, Resident 1's ADL's had declined to 3/2 (Extensive assistance/One person physical assist) for bed mobility, transfer, and toilet use. During a review of the clinical record for Resident 1, the physician's order dated 2/24/16, indicated "Acetaminophen 325 mg (milligrams) tab Tablet)- take 2 tabs (650) by mouth every 6 hours as needed for moderate pain (4-6). Another physician's order dated 11/13/15, indicated PAIN SCALE EVERY SHIFT, FOR PAIN SCALE OVER 0/10 DID RESIDENT EXCEPT PRN (as needed)-PAIN MEDICATION Y= YES, N=NO. The Medication Administration Record (serves a legal record of the drug administered to a resident) from the dates of 7/1/16 to 7/14/16, was reviewed. The following were noted; a) There was no pain scale documentation on the following dates (7/4/16, 7-3 day shift, 7/9/16, 3-11 PM shift and 11-7 night shift, and 7/12/16, 3-11 PM shift). b) Nurses signature was noted in the MAR (Medicine Administration Record) however, resident pain scale was not documented on the following dates (7/4/16, 7-3 day shift, 7/5/16, 7-3 day shift, 7/6/16, 7-3 day shift). c) There was no documentation of the location of pain for five of five days reviewed. d) There was no documentation of pain medication effectiveness for three of three days reviewed. e) Resident 1 complained of pain scale of 6/10, on 7/13/16, 3-11 PM shift and also on 11-7 night shift. However, there was no documentation a pain medication was given on both times. During an interview Licensed Nurse (LN) 1 on 7/14/16, at 12:55 PM, LN 1 verified the following: a) No pain scale was documented on the following dates (7/4/16, 7-3 day shift, 7/9/16, 3-11 PM shift and 11-7 night shift, and 7/12/16, 3-11 PM shift). b) The nurses were signing the MAR but pain scale was not documented on the following dates (7/4/16, 7-3 AM shift, 7/5/16, 7-3 AM shift, 7/6/16, 7-3 AM shift). c) There was no documentation of the location of pain for five of five days reviewed. d) There was no documentation of the pain medication effectiveness for three of three days reviewed. LN 1 stated he gave Resident 1 the Tylenol at 9 AM, however, did not follow up with Resident 1 for the pain medication effectiveness. e) The findings Resident 1 complained of pain scale of 6/10, on 7/13/16, 3-11 PM shift and also on 11-7 night shift. However, there was no documentation a pain medication was given on both times. At this time, LN 1 was informed the resident stated she had a pain scale of seven (7). LN 1 stated he would call the physician to obtain an order for another pain medication since the resident just had an order for Tylenol for pain scale of 4-6, and the resident's current pain scale was seven (7). During an interview with Resident 1 in her room on 7/14/16, at 1:22 PM, she stated due to the pain in her right arm, she was now staying more in her room. She could not propel her wheelchair like she used to. She needed more help with transfer and with all her activities of daily living. Resident 1 stated she loved to read books, but she could not read as much anymore due to the pain. During an interview with the Registered Nurse/Quality Assurance (RNQA), on 7/14/16, at 1:45 PM, she was informed there was no pain assessment/reassessment in the clinical record for Resident 1. RNQA provided a document titled PAIN FLOW SHEET (used to evaluate the effectiveness of the as-needed medication regimen) for the month of 7/16. However, the document was blank. RNQA verified the "PAIN FLOW SHEET" for the month of 7/16, was blank. No further information was provided. During an interview with the RNQA, on 7/15/16, at 12:30 PM, she was informed regarding the resident telling the staff she had a constant pain to her right arm. However, the facility had no documentation the resident's right arm was assessed until the resident's physician called the facility on 7/11/16, stating the resident's husband called saying the resident broke her arm and the facility was not giving the resident a pain medication. RNQA stated the facility should have done a pain assessment/re-assessment after the resident's fall incident. The facility policy and procedure titled Pain- Clinical Protocol, revision date 6/13, indicated under Assessment and Recognition "1. The physician and staff will identify individuals who have pain or who are at risk for having pain...2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a change in condition, and when there is onset of new pain or worsening of existing pain. 3. The staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain. Indicated under Treatment/Management "...3. The staff will evaluate and report how much and how often the individual asks for PRN (as needed) pain medication..." Indicated under Monitoring "1. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain...a. For example, review frequency and intensity of pain, ability to perform activities of daily living (ADL's), sleep pattern, mood, behavior, and interventions for pain..." These failures had a direct relationship to the health, safety, or security of residents. |
| 120001469 |
REDWOOD SPRINGS HEALTHCARE CENTER |
120013313 |
A |
10-Jul-17 |
DW6I11 |
13630 |
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.
On 2/24/17, at 10:00 AM, an unannounced visit was conducted at the facility to investigate an allegation of a resident-to-resident assault.
Resident 1 was a XXXXXXX year old female with diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with behavioral disturbances (The term behavioral disturbance refers to a pattern associated with subjective distress, functional disability, or impaired interactions with others or the environment), hypertension (high blood pressure), cerebral infarction (a blockage in the blood vessels supplying blood to the brain), difficulty walking, and muscle weakness.
Resident 2 was a 76 y/o male with the diagnoses of Lewy Body dementia (a type of dementia that manifest itself with hallucinations and violent behaviors), Parkinson's disease (A chronic disease of the nervous system that usually strikes in late adult life, resulting in a gradual decrease in muscle control), anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety), cognitive communication deficit (an organically caused decline from a previously baseline level of mental function), hypertension, and cerebral infarction.
The Department determined the facility failed to initiate one-to-one supervision (one staff member supervising one resident) for one of two sampled residents (Resident 2) who was admitted with known assaulting behaviors and maintain one-to-one supervision after he had assaulted another resident (Resident 1). This failure had the potential to place all residents in the Dementia Unit at risk of being assaulted by Resident 2.
A Dementia Unit is a separate and distinct unit within a long term care facility that segregates and provides a special program for residents with a diagnosis of dementia (a loss or decrease in intellectual ability that is of sufficient severity to interfere with social functioning, with symptoms such as memory loss, personality changes, poor reasoning or judgment, and language difficulties).
The clinical record for Resident 2 was reviewed. The hospital "Discharge Summary" record for Resident 2 dated 1/17/17, indicated "Dementia: Lewy Body (dementia), chronic, progressive, associated with behavioral issues, currently symptomatic with progressive decline in function and cognition, intermittent aggressive behavior, confusion...family unable to provide adequate care."
During a review of the transfer documents from the previous Skilled Nursing Facility for Resident 2 sent to the facility on XXXXXXX 17, the hospital "Progress report" dated 1/18/17, at 10:30 PM, indicated "Pt (Patient) had recent admission after he was found to be threatening to kill wife, others, and himself. He was placed 5150 (involuntarily confine a person suspected to have a mental disorder that makes them a danger to themselves, and/or a danger to others)."
The "Facility Activity Report" for Resident 2 dated 2/15/17, at 11:17 PM, indicated Resident 2 was involved in an incident in the Dementia Unit were he was the aggressor of an alleged resident to resident altercation.
The clinical record for Resident 1 was reviewed. The Nursing Progress Note for Resident 1 dated 2/15/17, at 9:40 PM, indicated, "At (approximately 9:37 PM) writer (Licensed Nurse-LN 4) was at the nurses' station charting when alarm on station 4 door started sounding. CNA (4) turned alarm off and assessed area. CNA (4) noticed resident (Resident 1) laying [sic] tipped over on w/c (wheel chair) on back, still buckled in safety belt. CNA (4) then called for nurse and assistance. Upon assessment, (Resident 1) had discoloration to bilat (both) eyes, bleeding from nose and mouth with swollen lips. Resident (Resident 1) responsive to name, complaining of body pain. Immediately called RN (Registered Nurse) sup (supervisor) to further assess, placed call to 911. During this event, staff members rushed down hall to assist (other staff members with the care to Resident 1), Resident (Resident 2) making references to (CNA 4) that he hit someone, he shot someone, someone call the police. This Resident (Resident 2) also noted with blood on left sleeve of shirt." Resident 1 was transferred to an acute care hospital Emergency Department for evaluation immediately after the incident. She was admitted to inpatient for treatment for eight days and was discharged back to the facility on XXXXXXX 17.
During a review of the hospital "History and Physical" dated 2/16/17, indicated Resident 1 "sustained facial trauma with nasal bridge lacerations (cuts), diffuse (spread) facial and periorbital (around eyes) swelling and chest ecchymosis (bruising), acute manubrium (upper part of chest bone) fracture, acute upper sternal (chest bone) fractures, acute R (right) 2-6 (2, 3, 4, 5, and 6th) rib fractures, acute L (left) 2-7 (2, 3, 4, 5, 6, and 7th) rib fractures, acute nasal bridge lacerations (cuts), acute facial contusions (bruising)...Due to the extent of her injuries possible assault could not be ruled out. Police Department contacted by ER (Emergency Room) staff and currently pending investigation."
The Nursing Progress Note for Resident 2 dated 2/16/17, at 8:04 AM, indicated "Events 02/15/2017 Aggressive/Combative...Staff noticed (Resident 2) walking in from station 4 patio with alarm sounding, staff checked outside to make sure all other residents were no longer outside. Staff noticed a resident (Resident 1) was on the floor, staff notified writer (LN 6) to help station 4 nurses assess resident (Resident 1). During assessment of resident (Resident 1) found on the floor, staff went back in building to get vital machine (a machine that assesses resident's blood pressure and pulse), and (Resident 2) stated to staff member (CNA 4) that he pushed (someone) outside down and have blood on sleeve of shirt...writer (LN 6) asked resident what happened. (Resident 2) was visibly distraught, stating that kids were making fun of him with a gun, and that he took the gun away and shot the kids. (Resident 2) then told other staff members that he took the gun away and hit the guy with it."
During a concurrent observation and interview with Resident 1, in the hallways of the Dementia Unit, on 2/24/17, at 10:27 AM, Resident 1 was observed in her wheelchair with a seat belt around her waist. Resident 1 had bluish, yellow discoloration around eyes, nose, checks, mouth, and right hand. Resident 1 was observed with a closed laceration on the ridge of her nose and discoloration to her mid chest area as she gently moved her blouse and softly rubbing her upper chest area. Resident 1 stated in Spanish, "It hurts so bad." She stated in Spanish, "I don't know what happened to me, I'm not sure how I was bruised. I hurt so much."
During an observation of Resident 2 on 2/24/17, at 11:46 AM, Resident 2 was walking outside in the social patio area for the Dementia Unit when other residents were present without staff in the area to supervise him. Resident 2 entered the Dementia Unit and walked the hallways independently without one-on-one supervision. During this observation, CNA 2 stated Resident 2 was not on one-to-one supervision but every 15 minute location checks.
During an interview with CNA 4, on 2/24/17, at 12:56 PM, CNA 4 stated as she responded to station door alarm she saw Resident 2 enter from the patio area. CNA 4 stated she opened the exit patio door to check the area and saw Resident 1 in her wheelchair tipped backwards with her legs up in the air. The back of her head was on the concrete. CNA 4 stated, "She (Resident 1) had blood on her face dripping on the concrete. Her coffee cup was on the concrete and bloody. She was still strapped in her wheelchair with her seatbelt, and (Resident 1) couldn't tip her wheelchair over. She had blood all over. Her eyes were purple, her nose looked broken, swollen, bleeding bad. Her lips were purple, swollen. She looked horrible, I screamed for the nurse to come...I ran to get towels to stop the bleeding, all the nurse responded... during all this (Resident 2) kept saying call the police, I killed someone, call her family too, call the police, I just killed someone because they had a gun."
During an interview with LN 4, on 2/24/17, at 1:33 PM, LN 4 stated when she arrived to the patio area she saw Resident 1 in her wheelchair on her back, with both of her eyes and lips were swollen and bruised. LN 4 stated Resident 1 had blood all over her face, and dripping from her nose and mouth. LN 4 stated Resident 1's coffee cup was found on the ground and it had blood all over it, like if she was hit with it. LN 4 stated after the incident she noticed Resident 2 had blood on his shirt sleeve.
During an observation of Resident 2 on 2/24/17, at 2:17 PM, Resident 2 was in the rehabilitation room performing exercises on an elliptical machine with a group of residents. Resident 2 was not observed with one-on-one staff supervision.
During an interview with Certified Nursing Assistant (CNA 4), on 2/24/17, at 5:23 PM, she stated "He (Resident 2) becomes aggressive with some residents, he starts walking towards them saying something about killing, he's been like that since he came here (2/8/17)."
During an interview with Certified Nursing Assistant (CNA 5), on 2/24/17, at 5:29 PM, he stated, "(Resident 2) becomes very anxious when residents are in his way. His eyes become wide and bulging and he yells out "you better get out of my way."
During an interview with Family Member (FM) 1, on 2/28/17, at 11:26 AM, she stated Resident 2 was hospitalized in a mental ward in January (2017) because he was trying to attack her with a hammer. She stated, "I was afraid. I called the police and they took him...they kept him on a 72 hour hold." FM 1 stated the hospital worked to stabilize his medications and then transferred him to a (Skilled Nursing Facility) in Fresno and he had behavior issues in that facility. FM 1 stated the Fresno facility transferred Resident 2 to the Visalia facility. She stated Resident 2's behaviors have been escalating for the past two years. He would become easily upset if he was told "No." FM 1 stated, "I was afraid for him, or if he hurt someone." FM 1 stated the current facility had knowledge of Resident 2's mental disorder history and dangerous behaviors towards others. FM 1 stated she took the discharge paper work from the other skilled nursing facility indicating Resident 2's behaviors to the current facility. She stated, "They had all the paperwork."
During an interview with Trauma Medical Doctor (TMD) 1, on 2/28/17, at 2:30 PM, TMD stated Resident 1 had severe facial injuries and multiple rib and sternal fractures that did not coincide with a ground fall from a wheelchair. TMD stated the injuries, based on her years of trauma experience, appeared to be related to an assault.
The care plan for Resident 2 titled "Behavioral Symptoms" dated 2/17/17, two days after the incident, indicated one-on-one supervision to ensure resident safety (one-on-one-when residents have a history of behaviors that might hurt themselves or others, the facility will have a staff member stay with the resident to decrease the chances of injury).
The "Psychologist Consultation" for Resident 2 dated 2/22/17, indicated "Staff reports resident shows agitation...is very difficult to re-direct is psychotic and aggressive towards others."
During a concurrent interview with the Director of Nursing (DON) and review of Resident 1's and Resident 2's clinical record, on 2/24/17, at 2:30 PM, the DON verified the above clinical record review findings for Resident 1 and Resident 2. The DON stated Resident 2 was not on a one-on-one supervision as indicated by Resident 2's behavioral care plan. The DON stated Resident 2 does not have a care plan for a resident-to-resident altercation because no one actually saw the altercation between Resident 1 and Resident 2. The DON stated she was aware that Resident 2 had a history of violent behaviors when Resident 2 was admitted to the facility.
The facility policy and procedure titled "Abuse Prevention" updated 2/9/17, indicated, "Abuse...will not be tolerated in this facility at any time. It is the policy of this facility to take proactive measures to prevent the occurrence of abuse to any resident...Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to...other residents... This includes the facility's identification of residents whose personal histories render them at risk for abusing other residents, and development of interventions strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior...Protection: (a) If a suspected perpetrator is another resident: Separate the residents so they do not interact with each other..."
The facility failed to supervise Resident 2, which resulted in Resident 2 assaulting Resident 1 causing her severe injuries. This violation of 483.25(d)(1)(2)(n)(1)-(3) presented imminent danger that death or serious harm to another resident would occur. |
| 120001469 |
REDWOOD SPRINGS HEALTHCARE CENTER |
120013318 |
A |
10-Jul-17 |
DW6I11 |
12694 |
F309
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.
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:
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
On 2/24/17 at 10 AM, an unannounced visit was conducted at the facility to investigate an allegation of an assault of one resident by another resident.
Resident 1 was a XXXXXXX year old female with diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with behavioral disturbances (The term behavioral disturbance refers to a pattern associated with subjective distress, functional disability, or impaired interactions with others or the environment), hypertension (high blood pressure), cerebral infarction (a blockage in the blood vessels supplying blood to the brain), difficulty walking, and muscle weakness.
The Department determined that the facility failed to provide pain relief for Resident 1 when she was experiencing severe pain from spinal, rib, shoulder and chest bone fractures she received from a resident-to-resident assault, which resulted in Resident 1 sustaining excruciating pain since she was discharged from an acute care hospital.
The clinical record for Resident 1 at the skilled nursing facility was reviewed. The "Resident Progress Notes" for Resident 1 dated 2/15/17, at 10:27 PM, indicated "At approx. (approximately) 21:37 (9:37 PM) writer (a Licensed Nurse-LN 4) was at the nurses station charting when alarm on station 4 door started sounding. CNA (4) turned alarm off and assessed area. CNA (4) noticed resident (Resident 1) laying [sic] tipped over on w/c (wheel chair) on back, still buckled in safety belt. CNA (4) then called for nurse and assistance. Upon assessment, (Resident 1) had discoloration to bilat (both) eyes, bleeding from nose and mouth with swollen lips. Resident (Resident 1) responsive to name, complaining of body pain...During this event, staff members rushing down hall to assist, resident (Resident 2) making references that "he hit someone, he shot someone, someone call the police'...Resident 1 left facility...at 21:51..."
Resident 1 was treated at an acute care hospital's emergency department on 2/15/17. She was then admitted to the hospital and returned to the skilled nursing facility on 2/23/17. The "History and Physical" dated 2/16/17, from the acute care hospital, indicated Resident 1"sustained facial trauma with nasal bridge lacerations (cuts), diffuse (spread) facial and periorbital (around eyes) swelling and chest ecchymosis (bruising), acute manubrium (upper part of chest bone) fracture, acute upper sternal (chest bone) fractures, acute R (right) 2-6 (2, 3, 4, 5, and 6th) rib fractures, acute L (left) 2-7 (2, 3, 4, 5, 6, and 7th) rib fractures, acute nasal bridge lacerations (cuts), acute facial contusions (bruising)." Resident 1 sustained multiple facial lacerations, fracture of sternum, five rib fractures to her right chest, and six to her left chest. Resident 1 was in severe pain and was managed by using two pain medications during her hospital stay: Norco and Lidocaine patch. Norco, a pain medication contains opioids. Resident 1 was prescribed to have Norco one tablet twice a day routinely and one tablet every six hours as needed. Lidocaine Patch is a local numbing medication. It works by blocking nerve signals in your body to reduce pain or discomfort caused by skin irritations such as sunburn, insect bites, poison ivy, poison oak, poison sumac, and minor cuts, scratches, hemorrhoids, and burns.
During a concurrent observation, and interview with Resident 1, on 2/24/17, at 10:20 AM, Resident 1 was observed sitting in her wheelchair while parked against the wall facing the nurses' station. Resident 1's face was observed with bluish, yellow skin discoloration around eyes, nose, checks, mouth, right hand and a closed laceration (cut) on the bridge of her nose. She was observed grimacing, moaning, clenching her chest while softly rubbing her upper chest area with her hands stating in Spanish, "It hurts so bad" while two nurses sat talking with each other approximately five feet away. Resident 1 stated in Spanish, "I have a lot of pain on my chest. I'm really hurting." Facility staff members were passing by as Resident 1 verbally expressed pain and was loudly moaning and grimacing. None of the staff stopped and addressed Resident 1's verbal and physical expressions of pain. Certified Nursing Assistant (CNA) 1 stopped and stated, "I'll take her to her room and you can talk to her there." CNA 1 wheeled Resident 1 to her room, parked her next to the bed, and walked away without addressing Resident 1's verbal and physical expressions of pain.
During an observation, in Resident 1's room, on 2/24/17, at 10:40 AM, CNA 2 and CNA 3 entered her room and asked Resident 1 if she needed something. Resident 1 stated in Spanish, "I'm in a lot of pain (points to her chest area and moans). I can't stand it, it hurts so much, so much, and I can't stand it." CNA 2 stated, "I'll call for a nurse."
During an observation on 2/24/17, at 10:45 AM, Licensed Nurse (LN) 1 entered Resident 1's room while Resident 1 was loudly moaning and grimacing stating in Spanish "It hurts so much, I can't stand it." LN 1 stated, "I'm going to get you a pain pill."
During an observation on 2/24/17, at 10:47 AM, LN 1 returned to the room and asked CNA 2 to translate in Spanish, "Tell her (Resident 1) that she already received a pain pill at 10 AM. She is not due for another pain pill yet." Resident 1 was moaning and grimacing as the nurse stood in front of her. CNA 2 translated in Spanish "The nurse said you already received your pain pill at 10 AM, and it's not time for another. They can't give you anything else. If they give you another pain pill, it's bad for you. So if your pain gets worst tell me." Resident 1 responded in Spanish, "It's really bad now, I can't stand it." Resident 1 was moaning stating repeatedly "I can't stand it, it hurts so much." CNA 2 translated Resident 1's response to LN 1, "She (Resident 1) said she's in pain."
During a concurrent observation of Resident 1 and interview with LN 1, on 2/24/17, at 10:52 AM, LN 1 stated Resident 1 had routine Norco (pain medication) twice a day and Resident 1 had received a Norco pill at 10 AM. LN 1 stated, "(Resident 1) has PRN (as needed) Norco every six hours but I can't give her anything." Resident 1 was moaning and grimacing in front of the nurse. LN 1 was asked if she understood CNA 2's translation of Resident 1's complaint of pain from the above observation at 10:47 AM. LN 1 stated yes and walked out of Resident 1's room without offering Resident 1 pain intervention options. At this time, CNA 2 and CNA 3 proceeded to provide help for Resident 1 to use the restroom. Resident 1 yelled out in pain as the two CNA's helped her stand and sat her on the toilet. Resident 1 began to moan loudly while on the toilet with CNA 2 and CNA 3 remained present in the restroom.
During a review of the clinical record for Resident 1, the "Medication Administration Record" (MAR), dated 2/24/17, indicated Resident 1 was to receive Norco one tablet twice a day and every six hours as needed. Resident 1 was admitted on XXXXXXX 17 at 4 PM. She received Norco at 9:39 PM the day of her admission and then another Norco at 10 AM on 2/24/17. Resident 1 did not receive any Norco as needed in between routine doses. During further review of Resident 1's pain assessment on re-admission on XXXXXXX17, there was no admission pain assessment found.
During a concurrent observation and interview with the Director of Nurses (DON), on 2/24/17, at 10:54 AM, the DON entered Resident 1's room and stated, "We are going to review her pain medication because in the hospital she was receiving Morphine (strong pain medication)." Resident 1 was moaning loudly while in the restroom. The DON walked out of the room without assessing Resident 1's pain or offering pain relief.
During an observation on 2/24/17, at 10:58 AM, Resident 1 asked CNA 2 and CNA 3 to help her to bed. Resident 1 stated, "Let me lie down maybe it will help the pain." CNA 2 and CNA 3 attempted to lie her down and Resident 1 yelled out "No, no, I can't stand it, it hurts." CNA 2 and CNA 3 stopped and helped Resident 1 back into her wheelchair. Resident 1 was moaning and grimacing. CNA 2 and CNA 3 left the room without offering pain relief. Resident 1 stated she was unable to do anything to alleviate the pain. She stated, "I just have to sit here and suffer, what else can I do?" She closed her eyes, became tearful and put her head back, moaning and grimacing.
During a subsequent observation on 2/24/17, at 11:25 AM, LN 2 entered Resident 1's room and asked CNA 2 to translate in Spanish. LN 2 handed CNA 2 a white paper with a line of faces with expressions and numbers at the bottom of each face. LN 2 asked CNA 2, "Ask her (Resident 1) to point to a face" indicating her pain. CNA 2 held the white paper with faces in Resident 1's face and asked her to point to a face with her pain. Resident 1 stated, "All of them...what can I do...I can't stand it, it hurts." LN 2 instructed CNA 2 to tell Resident 1 in Spanish "I can't give her anything, she has to wait." LN 2 was asked about Resident 1's pain rating, LN 2 stated, "She's moaning and grimacing so she's in a lot of pain. But I can't say how much pain because she can't tell me." Resident 1 continued grimacing and moaning as LN 2 walked out of the room without offering pain relief alternatives.
During an interview with the DON, on 2/24/17, at 11:40 AM, she stated, "She's in a lot of pain. I'm going to have the nurse call the doctor right now."
During an interview with the DON and LN 2 on 2/24/17, at 11:49 AM, LN 2 stated she had not called the physician. The DON instructed her, "Call the doctor and tell him of her pain and that we need something in a liquid form (liquid pain medication) right now. She's in severe pain."
During a subsequent interview and record review with the DON on 2/24/17, at 3:11 PM, the DON reviewed Resident 1's plan of care for 2/23/17 to 2/24/17 and provided a copy of it to the surveyor. The goal for "Will have s/sx (signs and symptoms) of pain managed with (in) 45 Minutes- 1 Hours after intervention rendered" was discontinued on 2/23/17. The "Approach" indicated "DC (discontinue) ON: 02/23/17-Discontinued Pain Assessment/Observation as Indicated." There was no further documentation found in the record to justify the decision to discontinue the pain assessment.
The facility policy and procedure titled "Pain Assessment and Management" dated March 2009, indicated "Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals...a. assessing the potential for pain;...c. Identifying the characteristics of pain; d. addressing the underlying causes of the pain; developing and implementing approaches to pain management...g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary...Recognizing Pain: a Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching...e. Limitations in his or her level of activity due to the presence of pain...4. The physician and staff will establish a treatment regimen based on consideration of the following: a. The resident's medical condition...c. Nature, severity and cause of the pain."
This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120001469 |
REDWOOD SPRINGS HEALTHCARE CENTER |
120013319 |
B |
10-Jul-17 |
DW6I11 |
8947 |
Health and Safety Code 1418.91:
(a) A long-term health care facility shall report all allegations of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
(b) A failure to comply with the requirements of this section shall be a class "B" violation.
On 2/24/17, at 10:00 AM, an unannounced visit was made to the facility to investigate an entity reported incident regarding a resident's fall with injury. During the course of the investigation, it was determined there was an allegation of abuse when it was suspected by facility staff that Resident 2 had caused Resident 1's fall during an assault.
Based on observation, interview, and record review, the facility failed to report an alleged abuse incident immediately, or within 24 hours for two of two sampled residents (Resident 1 and 2) when the incident was not reported to the California Department of Public Health. This had the potential for abuse incidents to go unreported to the Department.
The clinical record for Resident 1 was reviewed. The Nursing Progress Note for Resident 1 dated 2/15/17, at 9:40 PM, indicated, "At (approximately 9:37 PM) writer (Licensed Nurse-LN 4) was at the nurses station charting when alarm on station door started sounding. CNA (4) turned alarm off and assessed area. CNA (4) noticed resident (1) laying tipped over on w/c (wheel chair) on back, still buckled in safety belt. CNA (4) then called for nurse and assistance. Upon assessment (Resident 1) had discoloration to bilat (both) eyes, bleeding from nose and mouth with swollen lips. resident responsive to name, complaining of body pain. immediately called RN (Registered Nurse) sup (supervisor) to further assess, placed call to 911. During this event, staff members rushed down hall to assist, Resident (2) making references that he hit someone, he shot someone, someone call the police. This Resident (2) also noted with blood on left sleeve of shirt."
The hospital "History and Physical" for Resident 1 dated 2/16/17, indicated "(Resident 1) sustained facial trauma with nasal bridge lacerations (cuts), diffuse (spread) facial and periorbital (around eyes) swelling and chest ecchymosis (bruising), acute manubrium (upper part of chest bone) fracture, acute upper sternal (chest bone) fractures, acute R (right) 2-6 (2, 3, 4, 5, and 6th) rib fractures, acute L (left) 2-7 (2, 3, 4, 5, 6, and 7th) rib fractures, acute nasal bridge lacerations (cuts), acute facial contusions (bruising)...Due to the extent of her injuries possible assault could not be ruled out. Police Department contacted by ER (Emergency Room) staff and currently pending investigation."
During an interview with LN 4, on 2/24/17, at 1:33 PM, she stated CNA 4 responded to station four door alarm when Resident 2 walked in from the patio area. CNA 4 yelled for help. When LN 4 arrived to patio area she saw Resident 1 in her wheelchair on her back. LN 4 stated "Both of her eyes were black and blue, swollen, her nose was black and blue, swollen it looked broken. (Resident 1's) lips were black and blue, swollen, she had blood all over her face, dripping from her nose and mouth. (Resident 1's) coffee cup was found on the ground and it had blood all over it, like if she was hit with it. She looked so bad. She looked like someone hit her. After (Resident 1) was taken to the hospital, (Resident 2) kept saying call the police, I just killed someone, call the police." LN 4 stated, "(LN 7) informed the DON of the suspected resident to resident altercation because of what we saw and (Resident 2's) reaction." LN 4 stated, "(Resident 1) was tipped backwards in wheelchair on her back facing upward with her seatbelt on." LN 4 stated during the incident Resident 2 was observed with blood on his shirt sleeve. LN 4 stated the instruction staff received from administration was since no one witnessed the incident the staff could not call it abuse, therefore no one reported the allegation of physical abuse to the proper agencies.
During an interview with Trauma Medical Doctor (TMD) 1, on 2/28/17, at 2:30 PM, TMD stated Resident 1 had severe facial injuries and multiple rib and sternal fractures that did not coincide with a ground fall from a wheelchair. TMD stated the injuries in her trauma experience appeared to be related to an assault. TMD stated "In my experience...the extent of the injuries appeared to be questionable and possibly from an assault. The Emergency Room (ER) Physician and I agreed and ER staff called 911 and filed an abuse report and investigation."
During a review of the "Allegation of abuse Investigation- date of allegation 2/15/17" indicated "Location of incident: Unknown resident entered the east exit setting off the door alarm at approximately the same time that another resident was noted to have a fall outside. Date/Time: 2/15/17, at approximately 9:40 (PM): date/time reported: 2 /16/17, at 6:10 (AM) to the DON: not reported to the ombudsmen or CDPH (Department of Public Health). Administrator notified: Yes... Summary of the incident: (Resident 2) stated to staff member that he pushed the kid down and that staff didn't need to run outside to help, at the time resident was noted to have red on his sleeve that appeared to look like blood...he was visibly distraught, stating that "kids were making fun of him with a gun, and that he took the gun away and shot the kids." Resident then told other staff members that "he took the gun away and hit the guy with it... IDT (Intra Disciplinary Team) met and discussed findings and feels that allegation of resident to resident altercation is unfounded secondary to (Resident 2) having no recollection of the (Resident 1) falling outside and (Resident 2) was not witnessed near the resident (1) that fell."
During an interview with LN 4, on 2/24/17, at 1:33 PM, LN 4 stated Resident 1 looked like someone hit her. After (Resident 1) was taken to the hospital, (Resident 2) kept saying call the police, I just killed someone, call the police. (Resident 2) was a new Resident to us. (LN 6) spoke with the DON (Director of Nurses) and informed her of the severity of (Resident 1's) injuries and that we did not know what happened. The DON told (LN 6) that we had all night to figure it out. Then (LN 7) informed the DON of the suspected resident to resident altercation because of what we saw and (Resident 2's) reaction. The DON did not call back until the next morning." LN 4 stated Resident 1 could not receive injuries of that severity by falling. She stated "(Resident 1) was tipped backwards in wheelchair on her back facing upward with her seatbelt on." LN 4 stated during the incident Resident 2 was observed with blood on his shirt sleeve. She stated the instruction staff received from administration was since no one witnessed the incident the staff could not call it abuse, therefore no one reported the allegation of physical abuse to the proper agencies.
During an interview with the DON, on 2/24/17, at 2:30 PM, she stated, "Let me tell you my staff is assuming about (Resident 2)." She stated the nurses called her and informed her of (Resident 1) being found outdoors with severe facial injuries. The DON stated at around 6:15 AM, on 2/16/17, she read a text that was sent at around 12 midnight indicating the nurses suspected a Resident to Resident altercation. The DON stated "I didn't call it a Resident to Resident altercation because no one witnessed it, and both residents are confused. So to me (Resident 2) was making Delusional statements...He is not on a one on one..." The DON stated "I, the Administrator, and Regional Nurse Consultant agreed not to report it (physical abuse allegation) because no one witnessed it."
The facility policy and procedure titled "Reporting Abuse to Facility Management" dated revised October 2009, indicated when an alleged or suspected case of abuse or injures of unknown source was reported, the facility administrator, or his designee would immediately within 24 hours notify the Stated licensing and certification agency, the state Ombudsman, the Resident's representative, and Law Enforcement Officials.
This facility policy and procedure did not include the current State reporting requirements, AB 40 law: Welfare & Institutions Code Section 15610.67 definition of "Serious bodily injury" involving extreme physical pain, substantial risk for death, or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation: Physical abuse with serious bodily injury, report within 2 hours, written report (State Form) to Ombudsman, Law Enforcement, and CDPH (California Department of Public Health).
Therefore, the facility failed to report an allegation of abuse to the Department immediately or within 24 hours. |
| 230000606 |
RCCA - River Oaks |
230009233 |
B |
23-May-12 |
0XZG11 |
3982 |
A 008 W&I 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to ensure that Client 1 was free from verbal and physical abuse, when Direct Care Staff (DCS) A told Client 1 to "shut the f*** up" and slapped the top of his right hand. DCS A's behavior had the potential to result in injury, anxiety, or emotional trauma to Client 1 and the other clients residing in the facility. On 3/12/12 at 7:30 am, the facility reported to the Department, that DCS A verbally and physically abused Client 1 on 3/10/12. During an interview on 4/12/12 at 9 am, DCS A stated that she recalled the incident that occurred on 3/10/12 at 7 am, while she was assisting Client 1 with his shower. DCS A stated that Client 1 continued to yell loudly and she told Client 1 to "shut the f*** up," and when Client 1 touched her face, she only tapped the top of his right hand. Client 1, a 60 year old male, was admitted to the facility on 1/11/11 with diagnoses that included mental retardation, seizures, and right eye blindness. Client 1's profile and nursing care plans, dated 3/5/12, showed that he was non-verbal, non-ambulatory, and required extensive assistance with daily care.Client 1's individual behavior service plan, dated 12/12/11, addressed his behaviors of yelling loudly, biting his hand, and exhibiting signs of increased anxiety. The plan indicated that staff were to redirect Client 1 during these behaviors by use verbal and physical prompts such as asking if he would like to lie down, and evaluating if he was in pain and notify licensed nursing. During an interview on 4/11/12 at 2 pm, DCS C stated that on 3/10/12 at 7 am, she was helping DCS A give Client 1 a shower. Client 1 was yelling loudly, which is his normal behavior during showers. DCS C stated that DCS A yelled, "shut the f***up," which had no affect on Client 1 yelling. Client 1 then reached up and touched DCS A's face, DCS A responded, "are you serious" and slapped Client 1's right hand. DCS C stated that she then positioned herself between DCS A and Client 1 and finished showering him. On 4/11/12 at 2:15 pm, Licensed Nurse (LN) D stated she overheard DCS A cursing, then heard the sound of a slap, come from the shower room. LN D stated that she went to the shower room and saw DCS C standing in-between Client 1 and DCS A. LN D said that DCS C told her that DCS A slapped Client 1's right hand. LN D assessed Client 1 and was unable to see any sign of injuries. On 4/11/12 at 1:45 pm, House Manager (HM) B stated that DCS A was hired on 2/21/12, and that DCS A received orientation on clients rights and prevention of abuse, neglect, and mistreatment that same day. Behavioral training, client care, and special needs of persons with developmental disabilities were also completed by DCS A on 2/21/12. HM B stated that she investigated the incident and concluded from her interviews with LN D, and DCS A, and C that the allegation of abuse to Client 1's did occur. Client 1's right to be free of unnecessary physical and verbal abuse was violated on 3/10/12, during showering, when DCS A told Client 1 to "shut the f*** up," and slapped his right hand.This violation caused or occurred under circumstances likely to cause significant indignity, anxiety, injury or other emotional trauma to patients. |
| 230000605 |
RCCA - White Oaks |
230009597 |
B |
21-Mar-14 |
9D2211 |
3159 |
483.430(e)(1)Staff Training Program The facility must provide each employee with initial and continuing training that enables the employee to perform his or her duties effectively, efficiently, and competently. The facility must provide each employee with initial and continuing training that enables the employee to perform his or her duties effectively, efficiently, and competently.The facility failed to ensure that safety measures were effective for Client 2, while showering him as he was lying on a gurney and fell to the ground. This failure to provide a safe environment from unnecessary falls resulted in bruising with abrasions and swelling to Client 2's forehead, both knees, and feet/toes and crying in distress. On 8/8/12 at 3 pm, Direct Care Staff (DCS) C was giving Client 2 a shower while he was lying on the shower gurney (rolling device that allows a patient with limited body movement and strength to be transported to a bathing area. The patient can then remain on the shower gurney while being bathed), without the side rails raised and in locked position. When DCS C turned and reached for a wash cloth, Client 2 rolled off the gurney to the tiled floor. Client 2 was sent to the acute care hospital for an evaluation. Client 2 was a twenty-two year old male admitted to the facility on 7/23/09 with diagnoses that included mental retardation, cerebral palsy, seizure disorder, blindness, and contractures (joints were bent with limited movement) to both upper and lower extremities.Client 2 required total assistance with his care and had a gastric tube (a tube inserted into the stomach) used for food, fluids, and medications. On 11/8/12 at 11:45 am, Licensed Nurse (LN) D was interviewed. LN D stated she had worked that afternoon shift on 8/8/12, when she heard a noise and on investigation found DCS C in the shower room holding Client 2 under his arms trying to lift him off the floor and back onto the shower gurney. LN D stated she assessed Client 2 for injuries and visible red abrasions were noted on his forehead, both of his knees, and toes.LN D stated she interviewed DCS C about the accident and DCS C stated she did not use the safety rail on the gurney related to her pregnancy and the size of her stomach. DCS C stated she had difficulty getting close enough to Client 2 to shower him. On 11/8/12 at 12:15 pm, Administrator B confirmed that DCS C did not use the safety procedure of having the gurney side rail in the raised and locked position for showering Client 2.DCS C employee file was reviewed. She was hired on 6/23/11 with two days of orientation and two weeks with staff to staff orientation on showering all the clients at the facility. Therefore, the facility failed to ensure that safety measures were effective for Client 2, while showering him as he was lying on a gurney and fell to the ground. This failure to provide a safe environment from unnecessary falls resulted in bruising with abrasions and swelling to Client 2's forehead, both knees, and feet/toes and crying in distress.The violation of this regulation had a direct or immediate relationship to the health, safety, or security of patients. |
| 230000563 |
RCCA Augusta Lane #1 |
230010231 |
B |
11-Apr-14 |
XIWF11 |
7705 |
A 004 W&I 4502(d) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (d) A right to prompt medical care and treatment. The facility failed to provide Client 1 with prompt medical care and treatment when: The facility did not ensure that Client 1's physician was to follow her respite stay (temporary short time stay, allows caregiver several days off caring for client) while she was at the facility; The facility did not administer Gabapentin (used for seizures) 300 milligrams (mg) three tablets (900 mg) three times a day as ordered. Client 1 received 300 mg instead of 900 mg for 8 of 42 evening doses that resulted in six clustered (several short duration close together) seizures that required her to be sent to the hospital on 9/26/13; The facility did not clarify Client 1's diet of Nutren 1.0 (type of liquid nutrition, lactose intolerance and low residue) with fiber by GT (gastric tube inserted in the stomach for administration of medications, fluids, and nutritional supplements). Client 1 received 4 cans daily instead of 3 cans daily as ordered; and The facility did not verify that an alternate responsible party was designated and available to represent Client 1's treatment and care. The alternate responsible party was unable to provide current information since the Guardian was unable to be reached when there was a change in Client 1's condition.This failure resulted in a delay in treatment and increased risk for clustered seizures with possible injury resulting in hospitalization. Client 1 was a 27 year old female admitted to the facility for a 14 day respite stay on 9/19/13, while her Guardian was out of town and unavailable. Client 1's diagnoses included clustered seizures, blindness, profound intellectual disabilities, and received medications, fluids and nutrients through a GT. She was non ambulatory, non verbal and required total assistance with her care. On 10/17/13 at 8:15 am, the Administrator (Adm) was interviewed. She stated Client 1 was a last minute admission when the contracted facility that was scheduled for the respite stay backed out, this facility agreed to take her for the 14 days. Last minute information was given while the Guardian was off that afternoon, out of town. The Adm stated the nurse was unable to clarify the dosage of Client 1's seizure medications and diet against the written instructions provided from the Guardian and the medication bottles, due to conflicting directions. a. The facility's nursing staff requested clarification on medications and nutritional supplements from Client 1's physician. The physician refused to provide the information, because he had not been informed from the Guardian that Client 1 was at this facility for respite stay. b. When nursing went over Client 1's medication list, the two provided medication bottles for her seizure medications had different instructions that required clarification to administer correctly.The instructions from the Gabapentin bottle read 300 milligrams (mg) capsules take as directed by physician. However, the instructions from Regional Center A (provide oversight for placement of clients), dated 8/17/12, read Gabapentin 300 mg, 3 capsules three times a day (900 mg three times a day) for seizures. The dates Client 1 did not receive 900 mg of Gabapentin three times a day to prevent seizures were during the evening shift. Client 1 received only 300 mg on 9/19, 9/20, 9/21, 9/24, 9/25, 9/26, 9/27, and 9/28/13. Eight of 42 doses were 300 mg instead of 900 mg as ordered. The instructions from the Clonazepam bottle read 0.5 mg, to take one to three tablets when needed for chronic seizures. Regional Center A's instructions, dated 8/17/12, read Clonazepam 0.5 mg four tablets when Client 1 had a seizure to prevent cluster seizures. According to the facility's seizure record, Client 1 had a 10 second (sec) seizure on 9/22/13 with three Clonazepam given with good results. On 9/26/13, the cluster seizures started at 12:55 pm for 40 sec, 12:56 pm for 30 sec, 12:57 pm for 30 sec, with three Clonazepam given at 12:55 pm. Later the same day, she had a second cluster of seizures starting at 1:20 pm for 2 min, at 1:23 pm for 10 sec, a second one for 10 sec, and a third one for 15 sec seizures (the last three were within one minute). She then became unresponsive and 911 was called. Client 1 was transported to the emergency room where she received Lorazepam (used for relaxation to prevent seizures), Keppra and Lamictal (used for seizures) and potassium (electrolyte replacement) medications, prior to being discharged back to the facility. On 9/30/13 at 11:40 am, Client 1 had a 25 sec seizure with three Clonazepam given and no further seizures.c. There were two different instructions for Client 1's nutritional supplement. The Individual Service Plan (criteria-based objectives the individual was to achieve) by Adult Day Program, dated 7/26/13, noted that four cans of Nutren 1.0 with fiber were to be given every day through her GT. The physician's orders, dated 8/5/13, instructed to give nutritional supplement three times every day by GT. The facility had given Client 1 four cans daily from 9/19 through 9/30/13. Client 1 should have received three cans daily, as ordered. d. On 9/30/13 at 12:09 am, Licensed Nurse B documented that Client 1's GT became dislodged and Client 1 was sent to the hospital for GT replacement. At that time, Client 1's physician had been notified by the alternate responsible party who lived out of state, for information on the size of the GT and had reported that Client 1's physician would not provide the alternate responsible party, facility, or the hospital with that information, without prior approval from the Guardian. Client 1 was discharged home with her mother on 10/2/13. On 10/17/13 at 10 am, Adm stated that the facility failed to ensure that Client 1's physician was aware that an alternate guardian had been named by the Guardian alternate party to represent Client 1 for her treatment and care needs. Therefore, the facility failed to provide Client 1 with prompt medical care and treatment when: The facility did not ensure that Client 1's physician was to follow her respite stay while she was at the facility; The facility did not administer Gabapentin 300 mg three tablets (900 mg) three times a day as ordered. Client 1 received 300 mg instead of 900 mg for 8 of 42 evening doses that resulted in six clustered seizures that required her to be sent to the hospital on 9/26/13; The facility did not clarify Client 1's diet of Nutren 1.0 with fiber by GT. Client 1 received 4 cans daily instead of 3 cans daily as ordered; and The facility did not verify that an alternate responsible party was up to date on Client 1's treatment and care. The alternate responsible party was unable to provide current information since the mother was unable to be reached when there was a change in Client 1's condition. This failure resulted in a delay in treatment and increased risk for clustered seizures with possible injuries resulting in hospitalization. This violation had a direct and immediate relationship to the health, safety, or security of clients. |
| 230000560 |
RCCA - Augusta Lane #2 |
230010284 |
B |
14-Jan-14 |
0B4611 |
3294 |
A 008 W&I 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to protect Client 1 from verbal abuse on 3/6/13 at 9:30 am, when Direct Care Staff (DCS) A subjected Client 1 to the use of profanity, when the transport driver and transport aide brought Client 1 back to the facility for personal care. As a result of being subjected to DCS A's verbal abuse, Client 1 suffered fear, humiliation, and/or emotional anxiety. A review of Client 1's record disclosed he was admitted to the facility on 9/5/07 with the following diagnoses: Severe intellectual disabilities, quadriplegia (unable to control movement of legs and arms) and incontinence (unable to control bowel and bladder). He required extensive support with all his personal care including bowel and bladder care and was wheelchair bound. Client 1 attended a day program (program that teaches daily living skills to persons with intellectual disabilities) outside the facility. On 10/17/13 at 3:15 pm, the day program's transport aide (TA) was interviewed. TA stated after Client 1 boarded the bus, on 3/6/13, she checked the tie down straps for his wheelchair and discovered that Client 1 required care and brought him back to the facility for care. TA stated that DCS A appeared angry at her for bringing Client 1 back to be changed and said, "sh--" repeatedly while taking Client 1 up to the house.During an interview on 10/17/13 at 3:13 pm, the day program's transport driver (TD) stated that DCS A was visibly upset after Client 1 was returned to the facility for bowel care. TD stated that DCS A said, "sh--" and told Client 1 that she had just changed him. According to the facility's investigation report, dated 3/11/13, there were two other DCS, the transport driver and transport aide that overheard and witnessed DCS A's verbal abuse when transporting Client 1 to the house and back to the bus. The investigation documented that the facility's findings were conclusive, that DCS A had used inappropriate language multiple times, and subjected Client 1 to inappropriate language. During an interview on 10/17/13 at 11:30 am, the Administrator (Admin) stated that the DCS A was terminated (fired) after the investigation was completed.A review of a nurse's note dated 3/6/13, and timed 1:40 pm, described the incident and read, "Client 1 had appeared scared at time of occurrence." Therefore, the facility failed to protect Client 1 from verbal abuse when DCS A used inappropriate language when he needed bowel care.This violation had a direct relationship to the health, safety, security, and welfare of the client. |
| 230000606 |
RCCA - River Oaks |
230010318 |
B |
28-Feb-14 |
DP2I11 |
2144 |
W&I 4502(h) W&I 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to ensure that Client 1 remained free from verbal abuse on 9/14/13 at 10 am, when Direct Care Staff (DCS) A called Client 1 a derogatory (disrespectful) term. This had the potential to cause a negative impact on Client 1's physical and emotional well being. Client 1's record was reviewed and disclosed he was admitted to the facility on 1/11/11 with profound intellectual disability, blindness and seizures. He was non-verbal and non ambulatory and required two DCS assist with transfers and care.During an interview on 10/16/13 at 1 pm, DCS B stated that DCS A had used the phrase "fat a--" when they transferred Client 1 from his wheelchair to the bed on 9/14/13.During an interview on 10/16/13 at 12:30 pm, DCS A stated she called Client 1 a "chunky butt," and she did not think she was disrespectful to Client 1.During an interview on 10/16/13 at 10 am, the Administrator stated that DCS A said she had used the phrase "chunky butt" and was joking at the time. He confirmed that DCS A was suspended and terminated for verbal abuse. The facility's investigation report, dated 10/4/13, indicated that DCS A used a derogatory term with Client 1 that was inappropriate when talking with clients. Therefore, the facility failed to protect Client 1 from verbal abuse.This incident had a direct or immediate relationship to the client's health, safety, or security. |
| 230000606 |
RCCA - River Oaks |
230010319 |
B |
28-Feb-14 |
DP2I11 |
2005 |
1418.91(a) Health & Safety Code 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. The facility failed to report an allegation of verbal abuse to the California Department of Public Health (Department) within 24 hours. On 9/14/13, Direct Care Staff (DCS) A called Client 1 a derogatory (disrespectful) term. DCS B overheard the remark but did not report the incident until 20 days later, on 10/3/13. As a result, this failure had the potential to subject this client and others to repeated abuses during this period. On 10/16/13, Client 1's record was reviewed. He was admitted to the facility on 1/11/11, with profound intellectual disabilities, blindness and seizures. He was non-verbal and non ambulatory (unable to talk or walk) and required two DCS to assist with transfers and care.During an interview on 10/16/13 at 12:30 pm, DCS A stated she called Client 1 a "chunky butt," on 9/14/13, and did not think what she said was disrespectful.During an interview on 10/16/13 at 1 pm, DCS B stated that DCS A had used the phrase "fat a--" when they transferred Client 1 from his wheelchair to the bed on 9/14/13. She confirmed she did not report the incident to the administrator until 10/3/13, and was unable to explain why she delayed in reporting the incident to the administrator.On 10/16/13 at 10 am, the Administrator was interviewed. He stated that DCS A stated she had used the phrase "chunky butt" and was joking at the time, on 9/13/13. He confirmed that the suspected abuse was not reported by DCS B until 10/3/13, 20 days later.He confirmed that DCS A was suspended and terminated for verbal abuse and DCS B was suspended for not reporting immediately. Therefore, the facility failed to report DCS A's verbal abuse to Client 1 to the Department within 24 hours.This incident had a direct or immediate relationship to the clients health, safety, or security. |
| 230000460 |
River Valley Care Center |
230011204 |
B |
20-Jan-15 |
K5EC11 |
5847 |
AMENDED - Deadline for Compliance date changed from 1/26/2015 to 2/19/2015 T22 DIV5 CH3 ART5-72527(a)(11) Patient's Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (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 the rights of two patients to be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs, when two Certified Nursing Assistants (CNAs) A and B forced Patient 1 into bed against her will; and improperly transferred both Patients 1 and 2, resulting in emotional/physical distress for Patients 1 and 2 and had the potential to cause increased physical pain for Patient 2.On 10/1/13 at 1:16 pm, the Department received an entity reported incident alleging that two residents were handled roughly by two CNAs (CNA A and B). On 10/15/13, a review of a written statement by Nursing Assistant (NA) D, dated 10/1/13, disclosed that CNA A grabbed Patient 1's wheelchair and pushed Patient 1 into the room. NA D's description of Patient 1 was "resisting" when being pushed in the wheelchair. Further information from NA D's written statement disclosed that CNA A and CNA B proceeded to transfer Patient 1 by grabbing her arms under the armpit area, pulling her up by her pants, and moving her to the bed. NA D indicated in her written statement that Patient 1 had a "terrified look on her face." The statement read, "They kind of just threw her onto the bed..."On 10/15/13, during a record review, a statement written by NA E on 10/1/13 read, Patient 1 "...was resisting going into her room and backed herself out of the room. CNA A ...proceeded to forcefully push the wheelchair into her room..." NA E wrote that Patient 1's "feet were on the ground and she was resisting. Then once in the room, the CNAs stood on both sides of her, then grabbed her arms by her armpits. They asked her to stand up and when she did not; they grabbed her by the back of the pants and picked her up." a. Patient 1's record was reviewed. Patient 1, a 92 year old female, was admitted to the facility on 3/23/10 with diagnoses that included Alzheimer disease (deterioration of the memory) and macular degeneration (damage to the retina of the eye which may lead to loss of vision). Patient 1 was non-verbal and dependent on staff for getting in and out of bed. During a telephone interview on 10/16/13 at 3:15 pm, NA E confirmed that her written statement, dated 10/1/13, was accurate. NA E stated that Patient 1 continued to resist and at one point the CNAs "almost dropped her." NA E stated that once in bed, the CNAs did not lift or support Patient 1's head before pulling the pillow out from under her head to reposition her. During a telephone interview on 11/6/13 at 9:05 am, NA D confirmed that her written statement, dated 10/1/13, was accurate. NA D stated, "They almost dropped her." NA D stated that CNA A and CNA B "dropped her on the bed..." NA D stated that when the CNAs repositioned Patient 1, they did not support her head before they "snatched the pillow from under her head and put it under her feet." b. Patient 2's record was reviewed. Patient 2, a 101 year old female, was readmitted to the facility on 4/21/12 with diagnoses that included persistent mental disorder, hemiplegia (paralysis of one side of the body), and muscle weakness. She was unable to make her needs known and dependent on staff for all care including transfers. A document titled "Care Plan," dated 3/14/12, identified pain as a problem for Patient 1 evidenced by crying, moaning, and displaying a "sad, pained expression."A document titled, "Patient Progress Notes," dated 10/2/13 at 12:12 pm, disclosed a Licensed Vocational Nurse's (LVN) note which indicated that Patient 2's roommate, Patient 3, was watching CNA A and B as they transferred Patient 2 to her wheelchair. The note read, "Patient 3 stated that they threw her into her wheelchair this morning."A document titled, "Progress Note," dated 10/1/13 and timed 4:22 pm, disclosed a note written by the Social Services Assistant (SSA) which read, "Patient 3 stated that the CNAs grabbed her roommate and picked her up; she yelled. They always pick her up like that, hard and fast. They never use the machine. They pick her up by holding the back of her pants." During an interview on 10/15/13 at 1:50 pm, the Director of Nurses (DON) stated that the facility was a "no lift facility." When asked to explain a "no lift facility," he stated the staff utilized assistive devices to transfer or move patients when needed. He stated that CNA A and CNA B were "negligent" in the manner used to transfer both Patient 1 and 2, and did not follow the facility's "Safe Lifting and Movement of Residents" policy. Therefore, the facility failed to ensure the rights of two patients to be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs, when two Certified Nursing Assistants (CNAs) A and B forced Patient 1 into bed against her will; and improperly transferred both Patients 1 and 2, resulting in emotional/physical distress for Patients 1 and 2 and had the potential to cause increased physical pain for Patient 2.These violations had a direct relationship to the health, safety, or security of the patients. |
| 230000036 |
Riverside Convalescent Hospital |
230012578 |
B |
23-Sep-16 |
EQSS11 |
6948 |
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 one of two sampled residents (Resident 2) was free from abuse when Certified Nurse Assistant (CNA A) shoved Resident 2 onto her bed and refused to assist her to the bathroom. As a result, Resident 2 was not protected from abuse by CNA A which had the potential to negatively impact the resident's sense of security and psychosocial well-being and contributed to Resident 2 expressing her neck popped and was sore after being pushed so hard by CNA A. Resident 2's record was reviewed. Resident 2 was admitted to the facility on 9/21/14, with diagnoses that included seizure disorder, a healing fractured hip and high blood pressure. A minimum data set (MDS, an assessment), dated 3/19/16, indicated Resident 2 was cognitively intact (had the ability to think and reason) and had no symptoms of disorganized thinking or delusions. Resident 2 required the assistance of one staff member for dressing, walking, toileting and had some difficultly hearing. A review of a psychiatric consultation, dated 3/4/16, indicated Resident 2 had no symptoms of delusions (false fixed beliefs) and that Resident 2 described facility staff as being "Good people." A review of a document titled, "Social Services Progress Note," dated 3/16/16, indicated Resident 2 was very social with staff and had a history of "Fears that people (were) talking badly about her." A review of a report sent to the Department of Public Health (SOC 341), dated 4/14/16, indicated Resident 2 had reported to the facility an allegation of abuse from a staff member who had "Shoved her so hard on her bed that her neck popped" on 4/13/16, in the evening. An interview was conducted on 4/28/16 at 8 am, with the Administrator (Admin). The Admin stated CNA A had been identified as Resident 2's alleged abuser of 4/13/16 and was immediately removed from duty after Resident 2 voiced her complaint, and an investigation initiated. Social service progress notes, dated 4/14/16, were reviewed. The notes indicated Resident 2 told the social worker that her CNA (CNA A) the previous evening, had "Pushed me so hard that my neck popped." It also indicated Resident 2 told the social worker she now had a "sore neck." An observation and concurrent interview was conducted with Resident 2 on 4/28/16 at 8:15 am. Resident 2 was observed sitting up in her wheelchair, was well groomed, and had a slow speech pattern. Resident 2 stated she liked it at the facility "OK" and would rather be home, but knew she needed daily staff assistance. During the interview, Resident 2 was noted to sometimes misinterpret the question the surveyor asked and answered with a response irrelevant to the question. An interview was conducted on 4/28/16 at 8:15 am with CNA B. CNA B stated she had worked at the facility about one year and was familiar with Resident 2 and had frequently been her CNA. CNA B stated it was not usual for Resident 2 to make allegations of staff not caring for her properly. CNA B stated Resident 2 did need some minimal CNA assistance to get to the bathroom. CNA B stated Resident 2 did sometimes misinterpret what was being said to her and responded as if the topic of conversation is different that what it is. An interview was conducted on 6/16/16 at 4:20 pm, with a family member (FM) of Resident 2. FM stated he was aware of Resident 2's prior history of making accusations that staff were saying things about her. FM stated the allegations Resident 2 had made in the past were always verbal things Resident 2 perceived staff had said which affected Resident 2's self esteem. FM stated the allegation against CNA A was the first time Resident 2 had accused staff of any sort of physical misconduct. An interview was conducted on 6/14/16 at 3:35 pm with Licensed Nurse (LN) D. LN D stated she was very familiar with Resident 2. LN D stated that other than the allegation Resident 2 made about CNA A, Resident 2 had never made accusations of physical mistreatment by staff that she was aware of. LN D stated Resident 2 typically enjoyed socializing with staff. A care plan titled, Behavioral/Psychotropic Medication Care Plan," initiated 12/28/15, was reviewed and indicated Resident 2 had some paranoia behaviors and staff would provide a calm, supportive environment by speaking and moving calmly when assisting Resident 2. An interview was conducted on 6/16/16 at 10:10 am with Administrative Staff (AS) E. AS E stated Resident 2 had not made any allegations of staff physical misconduct, prior to the accusation regarding CNA A. AS E stated that she believed CNA A had been "problematic" in her interactions with residents. An interview was conducted on 6/16/16 at 11:20 am with Administrative Staff (AS) F. AS F stated she had participated in the facility investigation of Resident 2's allegations against CNA A. AS F stated that CNA A was "not friendly" to the residents, and prior to 6/13/16, had some problems with Resident 2 specifically. AS F stated CNA A had been "talked to" regarding providing care to residents who she (CNA A) thought should be more independent in their care. An interview was conducted on 6/24/16 at 2:30 pm with CNA C. CNA C recollected events of 6/13/16, which she had seen and heard transpire between Resident 2 and CNA A. CNA C stated that from the hallway, she saw CNA A in the doorway of Resident 2's room telling Resident 2, in a loud hostile fashion that she (CNA A) would not assist Resident 2 to the bathroom, that she (Resident 2) should do it herself ! CNA C stated that because it appeared CNA A was not going to assist Resident 2, she (CNA C) moved past CNA A and entered Resident 2's room to assist Resident 2, even though she was not her assigned resident to assist. A review of the facility's policy titled,"Reporting Abuse to Administrator," dated 1/1/2012, indicated the facility defined verbal abuse to include disparaging remarks directed toward the resident. The policy also indicated mental abuse was defined as, but not limited to, the withholding of services. An interview was conducted on 4/28/16 at 8 am with the Administrator (Admin). The Admin stated CNA A's employment had subsequently been terminated after her interaction with Resident 2 without CNA A resuming work, as CNA A "Did not meet standards." Therefore, the facility failed to ensure one of two sampled residents (Resident 2) was free from abuse when Certified Nurse Assistant (CNA A) shoved Resident 2 onto her bed and refused to assist her to the bathroom. As a result, Resident 2 was not protected from abuse by CNA A which had the potential to negatively impact the resident's sense of security and psychosocial well-being and contributed to Resident 2 expressing her neck popped and was sore after being pushed so hard by CNA A. |
| 230000036 |
Riverside Convalescent Hospital |
230012752 |
B |
9-Dec-16 |
4NO011 |
6252 |
F 205 483.12(b)(1)&(2) NOTICE OF BED-HOLD POLICY BEFORE/UPON TRANSFER Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the nursing facility, and the nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (b)(3) of this section, permitting a resident to return. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section. The facility failed to provide Resident 1 and/or his legal representative with a written bed hold notice when he was taken from this facility by the police to the hospital on a 5150 Hold (Section 5150 is a section of the California Welfare and Institutions Code (in particular, the Lanterman-Petris-Short Act) which authorizes a qualified officer or clinician to involuntarily confine a person suspected to have a mental disorder that makes them a danger to themselves, a danger to others, and/or gravely disabled).The facility then failed to allow Resident 1 to return to this facility after the 5150 was discontinued and he was medically cleared at the hospital. This resulted in a violation of Resident 1's right to return to the facility and the potential to adversely affect his physical and psychosocial well-being. The California Department of Public Health (CDPH) was contacted on 11/8/16 at 12:51 pm, by Administrative Staff (AS) at Hospital A to report that they had received, treated and medically cleared Resident 1 after he was sent to their emergency room (ER) on a 5150 Hold. AS reported that Resident 1 was brought into their ER after allegedly making suicidal comments combined with possible threats of harming other residents at the skilled nursing facility where he resided. AS reported that Resident 1 denied ever making these comments and was medically cleared by their ER physician and other outside mental health professionals. AS reported that Resident 1's facility refused to allow him to return and stated that he had not signed or been offered a 7-day bed hold and therefore they were under no obligation to take him back. Resident 1's record was reviewed during an onsite visit to this facility on 11/10/16. Resident 1 was a 78 year old male, admitted to this facility on xxxxxxx, with diagnoses that included previous blunt head trauma, cognitive deficits, history of polysubstance (many substances such as drugs and alcohol) abuse and homelessness. Resident 1's MDS (Minimum Data Set, an assessment tool) dated 10/27/16, indicated that Resident 1 had moderately impaired cognition. Resident 1 had no family or other representatives available to make care related decisions. Resident 1's record contained a nursing note dated 11/4/16, which indicated that he had told a staff member that he wanted a machine gun and was going to kill himself and anyone else who got it his way (the staff had previously found a suicide note written by Resident 1 on 11/2/16). The staff contacted Resident 1's physician and explained the situation. The physician instructed the staff to call the police for a 5150 assessment. Resident 1 was escorted out of this facility by three law enforcement agents and taken to Hospital A's ER at 6:15 pm. Resident 1's record contained a Bed Hold Agreement dated 11/4/16, which indicated that a bed hold was not offered to Resident 1 secondary to his 5150 status, which was needed for necessity of the resident's welfare due to his needs not being met and in order to protect the safety of the other residents. According to a history and physical from Hospital A, dated 11/5/16, the plan for Resident 1 was to be admitted for possible placement as his current nursing home was unwilling to take him back at this time. The report further indicated that Resident 1 had denied making any suicidal or homicidal threats and he had been cleared by outside mental health professionals who had rescinded the 5150 Hold. The report indicated that Hospital A admitted this homeless individual as they had no other place to send him. The physician reported that that due to Resident 1's cognitive abilities, he would not have been safe to be released on his own. During a concurrent interview and record review, on 11/10/16 at 11:30 am, with the Administrator (Admin) and Director of Nursing (DON), the Admin stated, "This is true, I refuse to take Resident 1 back." The Admin explained that she does not have the staff to adequately care for this resident or to keep her other residents' safe from his behaviors. The Admin and the DON acknowledged that Resident 1 had not been offered a bed hold prior to being sent out of the facility for evaluation, per facility policy. The facility's policy titled, "Bed Hold," dated 1/12, indicated that upon admission and when transferred to the hospital, the facility will advise all residents and/or their representatives in writing that the facility has a bed hold policy and will hold the resident's bed for up to seven days when the resident is transferred to the hospital. In an interview on 12/1/16 at 4 pm with AS at Hospital A, AS confirmed that Resident 1 remained there as a patient and that this facility continued to refuse to allow him to return home. Therefore facility failed to provide Resident 1 and/or his legal representative with a written bed hold notice when he was taken from this facility by the police to the hospital on a 5150 Hold and then failed to allow Resident 1 to return to this facility after the 5150 was discontinued and he was medically cleared at the hospital. This resulted in a violation of Resident 1's right to return to the facility and the potential to adversely affect his physical and psychosocial well-being. These failures had a direct or immediate relationship to the health, safety, or security of patients. |
| 240000413 |
RENEE HOUSE |
240008913 |
B |
17-Jan-12 |
MKMG11 |
5107 |
REGULATION VIOLATION: Welfare & Institutions 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 law of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denies 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. (i) A right to be free from hazardous procedures.The facility failed to ensure Client 1 was free from harm caused by hazardous procedures. On November 1, 2010, DCS wet mopped the kitchen floor during the time clients were still awake and active. Client 1 slipped and fell on the wet floor; he was sent to the emergency room for treatment of a laceration to the left side of his forehead, which required nine stitches to repair. On November 16, 2010 at 2:30 PM, an unannounced visit was made to the facility to investigate a fall incident, which resulted in a client sustaining a head injury. During this complaint investigation, it was determined that the facility staff failed to follow their policy and procedure to ensure clients' environment was safe and accident free at all times.This failure resulted in a fall in which Client 1 sustained a two centimeter laceration to his forehead and one centimeter laceration to his left eyebrow. Client 1 was discharged from the Emergency Room with a diagnosis of adult head injuries and a laceration to the face that required nine stitches as a result of his injuries. A review of Client 1's medical record showed a 61 year old male, admitted to the facility on February 18, 1988 with diagnoses that included severe mental retardation, deafness and schizoaffective disorder (a mental disorder characterized by elevated or depressed mood). An interview with the FM (Facility Manager) was conducted on November 16, 2010 at 2:35 PM; she stated that the DCS (Direct Care Staff) was mopping the floor that night (unable to recall the date). The FM stated Client 1 was agitated and was walking up and down toward the kitchen hallway. The DCS instructed the client to go to bed but Client 1 ignored DCS, walked on the wet floor in the kitchen, slipped and fell. Client 1 hit his head on the kitchen counter and sustained lacerations to his left forehead and eyebrow.An interview with the DCS (Direct Care Staff) was conducted on November 16, 2010 at 2:40 PM. He stated that he was mopping the kitchen floor on November 1, 2010 around 8:30 PM. Client 1 was awake and was walking toward the kitchen hallway. DCS stated he told Client 1 to go back but Client 1 ignored his warning. As a result, Client 1 slipped and hit his head on the kitchen counter. The DCS stated, "Basically it was my fault, I was mopping at night when clients are still awake."An observation of Client 1 was conducted on November 16, 2010 at 2:40 PM. He was alert and oriented but unable to answer verbally to questions. A wound with stitches about two centimeter long was noted on the left side of the forehead and a one centimeter wound with stitches was noted on his left eyebrow. A review of Client 1's Interdisciplinary Notes dated November 1, 2010 at 8:25 PM indicated a staff had mopped the kitchen floor while the clients were up and active. Client 1 walked on the wet floor and fell. Documentation showed Client 1 was transferred to the emergency room for treatment. A review of Client 1's Interdisciplinary Notes, titled "Emergency Room Visit," dated November 1, 2010, indicated that Client 1 was bleeding to his mid forehead and left eyebrow. Client 1 was transferred to the emergency room on November 1, 2010 and discharged on November 2, 2010. He had nine stitches; six stitches in the mid forehead and three stitches above the left eyebrow. Emergency room notes dated 11/2/10 showed that Client 1 was discharged from the emergency room on November 2, 2010 with a discharge diagnosis of, "adult head injuries and laceration on the face with sutures." A review of the facility's policy and procedure entitled, "Employee Consultation Guide and Samples," under safety concerns, stipulated that it was the primary responsibility of all employees to maintain a safe environment for all clients. Each employee was to closely supervise clients and remove unsafe objects from the client's environment.Based on these findings, the facility failed to ensure Client 1 was free from harm and hazardous procedures. Facility staff wet mopped the kitchen floor when clients were still active and further failed to prevent Client 1 from walking on a wet floor. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240001111 |
Rosewood House |
240009031 |
B |
22-Feb-12 |
TB3P11 |
14616 |
REGULATION VIOLATION: 483.460(a) Standard physician services (3) The facility must provide or obtain preventive and general care AND (c) The facility must provide clients with nursing services in accordance with their needsThe facility failed to follow the directives of the wound clinic after Client A developed pressure ulcers on her coccyx (tail bone) and right heel, by not obtaining an alternating air mattress, and not following the prescribed treatment to her coccyx. This resulted in Client A developing a Stage III pressure ulcer (full thickness loss exposing subcutaneous layers of tissue) on her right heel, and a Stage IV pressure ulcer (full thickness loss of skin and subcutaneous tissue exposing muscle and/or bone)on her coccyx. The wound on the coccyx required a surgical skin flap (due to the lack of blood supply to an area to promote healing, skin is removed from another part of the body and applied over the wound to promote healing), hospitalization and placement into a skilled nursing facility (SNF).The facility failed to ensure that the registered nurse (RN) identified, assessed and updated the medical care plan for Client A when she developed pressure ulcers on her coccyx and right heel. This resulted in Client A's wounds progressing and not healing. Client A was a 98 year old female admitted to the facility on January 26, 2001, with diagnoses to include: severe mental retardation (IQ in 20-34 range),seizures, hypertension (high blood pressure), osteoporosis (a thinning of the bones making them prone to fractures), congestive heart failure (the heart pumps weakly causing fluid to back up into lungs and extremities), Parkinson's disease (progressive loss of motor function with tremors and rigidity of muscles), cerebral vascular accident (stroke), and the placement of a gastrostomy tube (GT-a tube placed through the abdominal wall through which nourishment and medication can be administered). Client A was non-ambulatory and used a wheelchair for mobility when she was out of bed. Due to her age and declining abilities, she required assistance in all activities of daily living (ADLs) such as bathing, dressing and toileting. Client A was incontinent of both bowel and bladder.On February 25, 2011 at approximately 4:30 PM, Client A was transferred to Acute Care Hospital 1 for evaluation of the worsening pressure ulcer on her coccyx which was described as, "Stage IV pressure ulcer down to the fascia (a membrane that covers, separates and supports muscles). The measurements are 3 cm x 2 cm (1 inch = 2.54 cm) with the center area measuring 1.5 cm x1.5 cm, with a depth of 1.0 cm, and undermining between 6 and 8 o'clock of 2 cm, and 9-12 o'clock at 1.0 cm (the face of a clock is used to describe wound locations). The wound is 100% yellow slough (dead tissue) and necrotic tissue (dead tissue that has turned black), moderate drainage with a foul odor."On February 28, 2011, Client A was transferred to a specialty acute care hospital (Acute Care Hospital 2), for continued wound treatment. On admission the physician documented, "She has this wound for a significant period of time and it is not getting better with local wound care...The wound is preventing her from being treated in an alternative level of care..." Client A received a wound flap (skin is taken from elsewhere on the body, and placed over the wound in an attempt to heal it). Client A's clinical condition declined according to the discharge summary dated April 1, 2011. Her discharge diagnoses included acute respiratory failure, metabolic encephalopathy (her blood chemistry was altered and caused brain dysfunction) and sepsis (a bacterial infection in the blood, in her case caused by a urinary tract infection). The physician described Client A as, "...lethargic and unable to talk." She was transferred to a skilled nursing facility (SNF) due to her respiratory and wound care needs. A review of the Nursing Notes beginning on December 16, 2010 at 9:16 AM reflected the first entry documented by the staff related to the pressure ulcer on her coccyx. The documentation indicated, "Noted irritation on buttocks continued reddish, and open area approximately 1 inch circular. Mediseptic (a skin barrier cream with Lanolin in it) on area and another area (coccyx is written in the margins) area approximately 1/4 inch circular-open with serous (clear fluid) drainage."There was no documentation that the RN or primary medical doctor (PMD) had been notified of these findings. On December 17, 2010 at 9:30 AM, the nurse documented, "new order per [used PMD's name] for Dermagel (cushions and protects the wound. Can absorb up to 5 times its own weight in drainage), apply to irritated area on buttock every other day..."However, there was documentation that the RN had been notified of the new order. There was no documentation by the RN that she had assessed the wound. On December 27, 2010 at 9:30 AM, the Nursing Notes indicated, "DCS (direct care staff) noted on right heel approximately 1 inch circular skin breakdown. No signs or symptoms of drainage noted." The RN and qualified mental retardation professional (QMRP) were noted as being made aware. Two days later, on December 29, 2011 at 7:00 AM, the staff documented, "New orders for right heel. Cleanse and apply Mediseptic for 7 days and monitor." There had not been any mention of the status of the coccyx ulcer for the previous 11 days.There was no documented assessment by the RN of either the wound found on the coccyx or the right heel. On January 1, 2011 the RN documented, "Open area right heel inner aspect...same as when seen on December 30, 2010, by this RN-1 cm eschar (black dead skin) in center, with pink tissue surrounding...will follow up with MD on Monday (January 3, 2011)."During an interview with the QMRP, she was unable to locate any notes to indicate the RN had seen the heel wound before January 4, 2011, when the RN documented the following in the Physician Orders, "X-ray right foot/heel wound."On January 4, 2011, documentation in the Nursing Notes indicated, "Client was seen by [PMD's name] for ulcer on right heel...ordered an x-ray and follow up with (podiatrist's name- foot specialist)." There was no documented reference to the coccyx pressure ulcer. Three days later on January 7, 2011, under the Physician Orders (untimed), the RN documented, "New orders for treatment of coccyx pressure sore. Arrange wound clinic consult at [named acute care hospital 1]. Apply Bacitracin (antibiotic) ointment and cover with dry, sterile dressing."On January 7, 2011 at 5:00 PM, the RN documented, "Client has open area on coccyx, 3 cm eschar...4 cm extended redness around total wound...minimal drainage noted." The PMD was called and a nursing care plan was written. The "problem" was identified as, "Skin breakdown on coccyx." The "goal" listed was, "Area will be healed in 3 weeks with the date of January 28, 2011."On January 10, 2011, the physician ordered a consultation of the patient's coccyx pressure ulcer at the wound clinic.A review of the physical therapist's report from the wound clinic dated January 12, 2011 listed the diagnosis as,"Coccyx pressure ulcer unstaged." The therapist documented that Patient A was "on a regular hospital bed with an egg-crate overlay." The wound was described as, "An unstagable coccyx pressure ulcer that is dark purplish in color in the center with necrotic tissue present and pink around the wound margin. It is grossly 2.5 x 2 cm. The central 50 % is necrotic..." The physical therapist wrote, "The patient presents with an unstagable pressure ulcer on her coccyx in need of a better bed, low air loss mattress or pressure relieving surface." On January 12, 2011, the wound care clinic consultant documented, "Sacral decubitus ulcer Stage II or Stage III, with necrotic tissue debrided in clinic." The following order was noted, "Saline moist to dry dressing change every day, alternating air mattress or slow air loss mattress, and return in three weeks for follow up." On January 10, 2011 the nurse charted, "Client seen in wound clinic for assessment of coccyx wound. Area on coccyx was debrided and clean dressing on site. Clinic orders are "continue with current treatment order with Bacitracin ointment BID (twice a day) and dry dressing over site....Will see [Podiatrist's name] tomorrow for foot ulcer." A review of the Physician Orders and Nursing Notes following the wound clinic visit on January 12, 2011, did not reflect that these orders had been carried out, and there was no documentation that they had been discussed with the PMD if alternate orders were to be followed. The dates of the wound clinic visit and what is documented in the Nursing Notes do not match. Client A was seen in the wound clinic on January 26, 2011; the diagnosis was changed to, "Stage 3 decubitus ulcer on coccyx." New orders were for, "wet saline dressings, dry gauze BID and to return in two weeks." However, review of the Physician's Orders indicated that no orders were written after Client A returned from the clinic.Client A was seen again in the wound clinic on February 9, 2011. The physical therapist documented, "She is on air mattress in her facility". The treatment recommendation was, "Wet to dry dressing change BID...once whitish stuff comes off (dead tissue) change to A&D ointment and gauze."A review of the Medication Administration Record (MAR) for February 1-28, 2011 showed the order had been written as follows: "A&D ointment apply to affected area and cover with wet to dry dressing change gauze twice a day (coccyx area)." Documentation within the MAR showed the treatments had been done incorrectly from February 9-22, 2011. On February 23, 2011 Client A was seen again in the clinic and her coccyx wound was documented as, "Regressing Stage 4 pressure ulcer down to the fascia measuring 2.3cm central 1.5 cm x 2 cm open with depth of 1 cm and undermining 2 cm from 6 to 8 o'clock, 1 cm from 9-12 o'clock...1-2 cm redness in periphery. Wound 100% yellow slough, moderate drainage with odor." The recommendations were changed to, "Flush clean daily with 1/4 strength Dakin's Solution (an antiseptic solution used to treat infected wounds). Pack with saline moistened 1/2 inch gauze, cover with 4x4 and tape...low air loss bed, turn every 2 hours." A review of the Physician's Orders dated February 23, 2011, showed that the facility had ordered the recommended treatment including the low air loss bed. The RN's note dated February 23, 2011 at 4:30 PM, indicated that she had contacted Client A's case worker to determine the client's status related to "concern for stage of wound and slow healing and current treatment plan."The last documented wound assessment by the RN was dated February 10, 2011. In addition, there was no documented evidence that staff attempted to obtain the low air loss mattress. On February 24, 2011 Client A's wound was noted with a foul odor and an antibiotic was ordered. The following day at 4:30 PM, the RN assessed the wound and noted, "Foul odor, moderate amount of serous drainage...Client moaning more often..." The PMD was notified and ordered Client A transferred to the acute care hospital emergency room for, "evaluation of pressure sore on coccyx, pain and infection." A review of the "Report of Consultation" dated January 11, 2011, listed the podiatrist (foot specialist) as the consultant and the reason for the consultation as "ulcerations to right leg and foot." The findings included "There's a 1 cm x 1cm x 0.5cm wound located medial right heel... Hyperkeratosis (thickening and darkening of skin) surrounding the wound, yellow fibrous tissue and eschar cover the wound. (This indicates deep tissue damage)...positive tenderness to palpation.... Right heel x-ray report reviewed..." The doctor ordered, "Santyl (an enzymatic debriding agent) to be applied, "with dry dressing once a day." The physician recommended that Patient A return to the clinic in two weeks. A review of the Nursing Notes dated January 11, 2011, indicated "Client back from [podiatrist's names] appointment...new order of Santyl cream...apply cream and dry dressing...no tape used. Client has follow-up in two weeks." On February 15, 2011, Client A was again seen by the podiatrist, who documented the following pertaining to the ulcer on her right heel, "full thickness in nature at the posterior medial heel, right. The ulceration is 0.5 by 0.5 by 0.5 cm in size, no deep structures are exposed, no undermining, does not probe to bone." The podiatrist debrided the heel wound. A review of the Nursing notes from January 11, 2001 through February 15, 2011, reflected that the heel wound is mentioned on January 21, 2011 as, "...heel continue healing.."; on January 23, 2011, "Right heel decreasing in size", and on February 18, 2011, the nurse wrote that Client A had seen the podiatrist and he ordered, "Continue previous treatment to right heel and to offload right heel." No documentation could be found that described the wound to the heel. No care plan or wound measurements could be found for the right heel. During a phone interview with the RN on April 26, 2011 at 1:30 PM, She stated that she hadn't been measuring the heel wound "because she was being seen by the podiatrist for the heel." During the same interview when asked why the air mattress was not obtained as ordered, she stated, "She had a pressure relieving pad." When the RN was then asked where her documentation and reassessment of the coccyx wound, and care plan updates could be located in the chart, she stated, I only did weekly sheet on coccyx since wound was followed in the clinic." These findings were confirmed with the Quality Improvement Staff during chart review on April 26, 2011 at 2:00 PM. The failure of the facility to follow the directives of the wound clinic to obtain a low air loss mattress, and correctly applying the prescribed treatment to her coccyx wound, resulted in the progressive deterioration of the wound to a stage 4, which required hospitalization, a skin graft and transfer to a SNF. The failure of staff to monitor her heel wound resulted in that wound deteriorating to a stage 3 ulcer. The failure of the facility's RN to identify potential wounds and assess actual wounds, review the appropriateness of recommended treatments, and document her findings in the Nurse's Notes and on a plan of care, resulted in Client A's wounds progressing and not healing. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000286 |
Rimrock Villa Convalescent Hospital |
240009386 |
B |
05-Jul-12 |
0V3O11 |
10196 |
REGULATION VIOLATION: Title 22 72311 Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the care plan as necessary by 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.AND(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 staff failed to revise the plan of care by failing to ensure that a mechanism was in place to alert staff to Patient A's movement when she ambulated in her room without calling for assistance. The facility staff failed to implement the plan of care by failing to ensure that Patient A was provided supervision and assistance with ambulation. On September 12, 2011, Patient A fell in her room and sustained an injury to her right arm. The patient was transported to the acute care hospital emergency room and was diagnosed with a right arm fracture (broken bone). The patient required surgical intervention and hospitalization. On October 6, 2011, Patient A's medical record was reviewed. It noted that the patient was admitted to the facility on March 22, 2010 with osteoporosis, difficulty walking and dementia (main symptoms are usually loss of memory, confusion, problems with speech and understanding, changes in personality and behavior and an increased reliance on others for the activities of daily living). The Minimum Data Set (MDS, a comprehensive assessment of the patient) dated September 9, 2011, showed that the patient usually understood others and had impaired long and short term memory loss. Documentation indicated Patient A required supervision and set up help for bed mobility, transfer, ambulation in room and toileting. A review of the nurses notes dated September 12, 2011 at 6:45 AM, indicated that Patient A was found lying on the floor on her stomach. The patient complained of pain to her right arm, which showed swelling and bruising. Also, a small swelling was noted above her right eye. The physician was called, new orders were received, and the patient was transported to the acute care hospital for evaluation and treatment. A review of the physician's annual history and physical completed on March 1, 2011, noted that Patient A had fluctuating capacity to understand and make decisions.A review of the care plan titled, "At risk for physical injury from falls related to dementia, pain and fall assessment score of 24" initiated on March 16, 2011, included the following: a. Falling star program: (Patients in this program are recognized by a star or a leaf on his or her door, wheel chair, walker, and other items used for ambulation. The care plan is revised and updated as needed to reflect current fall risk and patient-specific interventions designed to reduce recurrence. Facility staff is educated to recognize that residents participating in the Falling Stars/Falling Leaf Program (as identified by a star/leaf) may be limited in safety awareness, have a greater potential to fall, and require more diligent supervision. Staff is encouraged to the following: * When passing by a Falling Stars/Falling Leaf (patient) resident room, take a few seconds to survey the room to promote safety. * If a resident in a wheel chair is trying to stand, a resident is trying to climb out of bed or if a resident is staggering, stooping, or reaching for objects out of reach, assist the resident and then report the incidents to the charge nurse). b. Floor mat on both sides of the bed. c. Assist with transfers as needed. d. Assist of 1 person with ambulation. e. Chair alarm (an alarm box with a string attached to the alarm and a clip at the other end of the string. The clip is attached to the patient's clothing. When the patient moves and the string separate from the alarm box, it makes a distinct sound that alert staff to the patient's movement) when in wheel chair or chair; keep audible to staff f. Bed alarm (same as chair alarm) when in bed; keep audible to staff. g. Bed in low position for transfer in and out of bed. h. Monitor and encourage use of proper footwear. i. Non-skid material in w/c or chair. A review of the care plan titled, "At risk for physical injury from falls related to dementia, pain and fall assessment score of 24" initiated on March 16, 2011 and revised on June 1, 2011, included the following: j. Restorative Nursing aide (RNA) for transfer training 6 times (x) a week x 3 months. k. RNA for range of motion (ROM) for upper and lower extremities (arms/legs), 6 x a week, x 3 months. l. RNA for bed mobility 6 x a week, x 3 months. m. RNA for ambulation with gait belt 6 x a day for 3 months. A review of the fall risk assessment completed on June 14, 2011, showed a score of 24. The fall risk assessment indicated that the patient had impaired cognitive behaviors, moderately impaired vision and had problem ambulating and used a front wheeled walker. Interventions included, call light within reach and 1-2 staff members for transfers. A review of the care plan titled, "At risk for physical injury from falls related to dementia, pain and fall assessment score of 24" initiated on March 16, 2011 and revised on June 28, 2011, included the following: e. Discontinue the chair alarm when in wheel chair or chair; keep audible to staff.f. Discontinue the bed alarm when in bed; keep audible to staff.On October 6, 2011, at approximately 1:05 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1, who was assigned to provide care for Patient A on September 12, 2011, during the day shift (6:30 AM to 2:30 PM). CNA 1 stated that she was assisting another patient when she heard a scream and a bang coming from Patient A's room. When she entered the room, the room light was off, and the patient was lying on the floor, face down. The patient rolled herself over on to her back and complained that her right arm hurt. At that point, 2 Licensed Vocational Nurses (LVN) and another CNA entered the room and assisted the patient. During the same interview, CNA 1 stated that after the fall, Patient A was more confused than usual. The patient was not aware of the fall or that she was lying on the floor. The patient denied falling and stated that she was in her bed. CNA 1 stated that prior to the fall; Patient A was independent with ambulation, toileting and activities of daily living and did not call for assistance.A review of the care plan titled, "Impaired mobility requires minimal to moderate assistance with ADL's related to dementia and chronic pain" initiated on March 16, 2011, included the following: Goal: "Resident will be able to ambulate safely with walker assistance and one person." Intervention: "Assist with positioning, transfers, ambulation as necessary or as requested by resident." A review of the facility policy titled, "Falls Management," undated, included the following: "...e. The care plan is revised throughout the course of treatment by the interdisciplinary team to assure the most recent, updated and resident specific fall reduction interventions have been incorporated as necessary into the plan of care." On October 12, 2011 at approximately 9:57 AM, an interview was conducted via the telephone with LVN 1, the night nurse who responded to Patient A's fall on September 12, 2011. LVN 1 stated that the patient could not verbalize what happened. LVN 1 stated that prior to the fall Patient A did not call for assistance and was independent with ambulation in her room and to the bathroom. LVN 1 stated that she was not aware that the MDS and the "At risk for physical injury from falls" care plan, noted that the patient required supervision and assistance with ambulation.An interview was conducted on October 27, 2011, at approximately 2:35 PM with the MDS coordinator. The care plan titled, "At risk for physical injury from falls related to dementia, pain and fall assessment score of 24" initiated on March 16, 2011 and revised on June 28, 2011, was reviewed along with the MDS, which was completed on September 9, 2011, 3 days prior to the fall. The MDS coordinator confirmed that Patient A was not independent with ambulation and required supervision and assistance. The MDS coordinator stated that at times, Patient A was able to follow command and made her needs known but was forgetful. An interview was conducted on October 27, 2011, at approximately 2:40 PM with Registered Nurse (RN) 1, the nursing supervisor. Patient A's fall care plan was reviewed. RN 1 stated that the tab alarm in the wheel chair and in the bed was discontinued on June 28, 2011, because the patient continued to disconnect the alarms. RN 1 was asked what mechanism was in place to alert staff of Patient A's movement in her room, since the patient did not call for assistance. RN 1 responded that the "Falling Star Program was in place and that the patient was checked on frequently.? An interview was conducted on March 20, 2012, at approximately 9:50 AM via the telephone with the Administrator. The Administrator was asked, "What mechanism was in place prior to the fall to alert staff of the patient's movement?" The Administrator responded that the patient was independent with ambulation. The MDS completed on September 9, 2011, 3 days prior to the fall was reviewed. It indicated that Patient A required supervision for ambulation in the room and limited assistance of one person assist with ambulation in the hallway. The Administrator stated, "The Falling Star/Falling Leaf Program was in place at the time of the fall; it included frequent checks on the patient." The Administrator did not respond when asked, "What happened in between the frequent room checks?" "How was the staff alerted when Patient A was up and ambulating in her room without supervision?"These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000853 |
RAINBOW HOUSE |
240012273 |
B |
23-May-16 |
T8IW11 |
7837 |
REGULATION VIOLATION: 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. FINDINGS: The facility failed to monitor and supervise Client 1 when DCS 1 (direct care staff) left the client unattended in the facility while assisting other clients to the facility van for an outing. Subsequently, Client 1 opened the front door and wheeled herself outside. Client 1 took her seat belts off, stood up and fell face down on the ground.This failure resulted in Client 1 sustaining an injury, which required a transfer to the Emergency Room where Client 1 received a diagnosis of a fractured (broken) bone of the neck and spine (backbone). The hospital discharged Client 1 with a neck and upper body brace, which prevented her from attending the day program (a program that helps adults with physical and intellectual disabilities to achieve and improve their skills) from July 11, 2015 through October 2, 2015 (for two months and two days). She required medication to control her pain.A review of the facility's "Special Incident Report" dated July 13, 2015, indicated, "while staff were getting the clients in the van for an outing, Client 1 had rolled her wheelchair out of the door and in doing so, she fell out of the chair onto the ground. Staff noticed she had taken her seatbelt off. ...Client 1 was in pain when touching her neck area. She was transported to the hospital and was diagnosed with a fractured neck and/or spine."On July 16, 2015 at 3:15 PM, during an unannounced visit, Client 1 was observed sitting on the wheelchair wearing a neck and upper body brace. Client 1 was alert, smiling, and showed no signs of pain or distress. Client 1 was able to follow simple directions. She was able to communicate by using some sign language.During a telephone interview with the Qualified Intellectual Disability Professional (QIDP), on July 16, 2015 at 3:20 PM, she stated Client 1 was able to ambulate with assistance. The QIDP said she (Client 1) used the wheelchair to move around because she walked unsteady. She stated Client 1 is able to release her seat belt and get up. The QIDP stated during this incident, Client 1 was left alone in the wheelchair and unattended inside the house while the Facility Manager (FM) and the Direct Care Staff (DCS 1) transported other clients to the van for an outing. Client 1 opened the entrance door and wheeled herself out. She took her seat belt off, stood up and fell on the ground. She was transferred to the emergency room and was diagnosed with a fractured neck and spine. She was discharged from the hospital and was received back to the facility with a neck and body brace, which she would be wearing temporarily until she heals.During an interview with DCS 1, on July 16, 2015 at 3:30 PM, she stated the FM and I were loading the clients to the van for an outing. She stated they took the clients out, but left Client 1 alone in the house. Client 1 opened the entrance door and wheeled herself outside, took her seat belt off, stood up and fell on her face on the ground. She confirmed the findings and stated she should have not left the client alone in the house while in the wheelchair because she can remove her seat belt and can get up. She stated Client 1 was transported to the emergency room.On July 21, 2015 at 4:50 PM, during a telephone interview with the Registered Nurse (RN 1), she stated staff reported to her that Client 1 had a fall outside of the house. Client 1 fell from the wheelchair, face down onto the ground after she took her seat belt off. She stated Client 1 was taken to the hospital after complaining of pain and inability to move her neck. She stated an x- ray of the client's neck and spine was taken. RN 1 stated she received information from the hospital that Client 1 had a fractured neck and spine. RN 1 said she had not received the actual X-ray results, however the emergency room physician had reviewed the results and it indicated a fractured neck and spine. She stated Client 1was discharged with a neck and body brace and prescribed medication to control her pain. A review of Client 1's medical records indicated, Client 1 was admitted to the facility on August 28, 1990, with diagnoses that included, profound intellectual disability (a generalized disorder characterized by significantly impaired mental functioning) and cerebral palsy (a disorder that involves the nervous system function such as movement, learning, hearing, seeing and thinking).A review of the nursing notes dated July 11, 2015 at 5:20 PM, written by RN 1 indicated, "The resident (Client 1) was confirmed to have a cervical (neck) fracture and will be transferred to .... hospital for further evaluation."A review of the nursing notes written by RN 1, dated July 12, 2015 at 12:00 PM, showed, "Resident (Client 1) agitated and pulling off neck and body brace, Resident is redirected....PRN (as needed) Motrin given with D/C (discharged) order of PRN Norco (pain medication)."A review of Client 1's most recent nursing care plan provided by the QIDP was nine months ago, dated October 16, 2014, which indicated Client 1 was at risk for falls and injury R/T (related to) unsteady gait. The plan of care indicated, direct care staff (DCS) to monitor client during ambulation at all times. DCS to assist client with ambulation as needed, using assistive device as ordered by the physician.There was no current nursing care plan or a current Individual Program Plan (IPP, a treatment plan to help clients improve their overall health, physical and intellectual status) for Client 1 to address the client's lack of safety awareness when getting up from the wheelchair unsupervised. There was no current nursing care plan that addressed the client's ability to unlock her seat belt, which would make her a high risk for falls and injuries.A review of Client 1's Physical Therapy Evaluation dated May 1, 2015, showed "History of independent ambulation with walker, has been labored over past few years."A review of the emergency room treatment record dated July 11, 2015, showed Client 1 sustained a "C 1- C 2 (cervical {neck}) fracture (broken neck) as a result of a fall from a wheelchair, face first on the grass, unwitnessed."The emergency room treatment record also indicated, an MRI (Magnetic Resonance Imaging, (a medical imaging used to detect structural abnormalities of the body) was done on July 11, 2015, which showed cervical (neck) spine fracture.Client 1 was discharged from the ER to the home on July 12, 2015 with a neck and body brace on.During an interview with the QIDP, on October 2, 2015 at 4:15 PM, she stated Client 1 had been wearing her neck and body brace after the incident and had not attended the Day Program since. She stated, "The Day Program would not accept her."A policy and procedure for client's safety while in a wheelchair was requested from the QIDP, however no policy and procedure was provided. The facility failed to monitor and supervise Client 1 who had no awareness of the hazard of falling after unlocking her seat belt and getting up from the wheelchair. Direct Care Staff 1 (DCS 1) failed to ensure Client 1 was not left alone and unsupervised. Subsequently, Client 1 opened the front door and wheeled herself outside. Client 1 took her seat belts off, stood up and fell face forward to the ground, which resulted in a fall with injuries.This violation had a direct or immediate relationship to the health, safety or security of the clients. |
| 240000150 |
REDLANDS HEALTHCARE CENTER |
240012429 |
A |
22-Jul-16 |
SXJH11 |
8512 |
REGULATION VIOLATION: Title 22 72523 (a) Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to follow their policy and procedure to ensure that staff tested the high/low calibration quality controls (a daily test of the glucometer using liquid controls, a testing solution, to make sure the machine is working properly. Both a "low" and a "high" test must be performed daily by nursing staff on the glucometer [a handheld machine used to check blood glucose (blood sugar) levels for patients with diabetes (blood sugar is too high)] calibration quality controls were accurate. This failure had the potential to result in the glucometer providing inaccurate blood glucose results, causing the nurses to administer an incorrect dose of insulin, based on the individual physician orders, which could lead to hypoglycemia (low blood sugars) or hyperglycemia (high blood sugars) and cause serious harm, shock, coma or death for 24 patients (Patients A, B, C,D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X) with a diagnosis of diabetes, and physician orders for insulin. On November 5, 2015, a review of the "Daily Quality Control Record" (used to document the results of the glucometer calibration quality control testing) from Station One reflected the log page dated October 11, 2015 through November 2, 2015, 13 of the "high" result numbers were found to be out of range. The normal range for the ?high? controls ranged from 228-280. The recorded results for the ?high? results ranged from 168-213. During a concurrent interview with LVN 1, she stated when the results of the glucometer controls are out of range the Director of Nurses (DON) is to be notified. LVN 1 stated there was no other form where the nurse documents quality control results that are out of range, and she only "reports [the results] verbally to the supervisor." During a review of all of the 2015 "Daily Quality Control Records," for Nursing Station One, and for Nursing Station Two, there was noted to be a total of 41 documented results which were out of range for the high controls from the dates of April 15, 2015 through October 31, 2015. Thirty-one of the results were recorded by LVN 2. The other ten were recorded by four other LVNs (LVN 1, LVN 3, LVN 4 and LVN 5). During an interview with the DON on November 5, 2015 at 6:35 AM, she confirmed the control results were "out of range" on the Daily Quality Control Records. The DON described the informal protocol used to monitor the ?Daily Quality Control Records, and stated the "RN (Registered Nurse) supervisor (RNS) reviews the log for accuracy.? During an interview with the Administrator and the DON on November 5, 2015 at 7:10 AM, the Administrator stated they had talked to LVN 2 who checked the glucometer controls, and who recorded the out of range numbers thirty-one times. The Administrator stated LVN 2 admitted to them that she [LVN 2] "just made up the numbers, and she did not ever run controls on her shifts." The Administrator stated, ?We have suspended the nurse. She will be written up, which will lead to termination. The DON stated Quality Assessment had started a project on ?Accu-checks? (a brand name glucometer for blood glucose level testing) in August 2015, because the facility had identified "gaps" on the logs [blank spaces on the Daily Quality Control Records], but she was not aware of the high range controls documented out of range. During an interview on November 5, 2015 at 8:50 AM, with the RNS for Nurse's Stations One and Two, when asked about her role in overseeing the glucometer logs, she stated, "I make sure they are being done; they should be done every morning, but priorities have to come first." She stated, "Medication nurses should report to the charge nurse or the supervisor if controls are out of range. If they are out of range, we recalibrate or change to a new glucometer." After RN Supervisor 1 confirmed that on one page of the glucometer log (from October 11, 2015 through November 2, 2015) at Nurse's Station One, there were 13 out of 30 results recorded out of range, she stated, "Supervisor only checks to make sure it is done; it is the responsibility of the LVN charge nurse to tell the supervisor at change of shift if the results are out of range." When asked where the staff document glucometer calibration quality control results or replacement of the glucometer, the RN supervisor stated, "Nothing is written down, we just fix it." When asked if she knew the 13 results on the one page were out of range, RN Supervisor 1 stated, "No." During an interview with the DON on November 5, 2015, at 12:15 PM, she stated, "Some of the nurses report to me that the glucometer was out of range... the controls were off, maybe last month, but it was a battery issue. We haven't changed out the glucometer itself in over 3 months." When asked if the discrepancies (out of range results) on the glucometer calibration quality control log were identified by anyone at the facility, the DON answered, "No." When asked if the facility had identified gaps on the log, but did not check for results or accuracy, the DON stated, "Yes.? During an interview on November 5, 2015 at 3:08 PM with LVN 3, a day shift nurse, she stated that night shift nurses check blood sugars of patients using the glucometer, as early as 5:30 AM daily, and give insulin before the day shift nurses come on duty at 7:00 AM. LVN 6 also stated that "night shift checks the glucometer, checks the controls and makes sure the machine is ready for the day shift." During a telephone interview with LVN 2, on November 9, 2015 at 3:15 PM, she confirmed it was her responsibility as the night shift charge nurse, to check the controls of the glucometer each morning. When asked if she could explain the process to follow when the controls were out of range, she stated, "No, not really, and to be honest, I didn't even know what the normal range was." When asked if she had ever notified anyone at the facility that she had out of range results, she stated, "No." LVN 2 stated, "I didn't report it when it [glucometer controls] was out of range." LVN 2 stated that she normally did the morning blood sugar check with the glucometer on the patients before breakfast and that she also gave long acting insulin and regular insulin based on the results she received with the glucometer. LVN 2 stated on orientation, no one ever watched her run controls. She also said the DON did not spend time with her on orientation. During an interview with the DON on November 10, 2015 at 7:45 AM, she stated, "New nurses spend two days with the Director of Staff Development (DSD), then shadowing with experienced staff for three to four days, and I personally check all skills with the nurses." The DON stated she had personally watched LVN 2 perform the glucometer skills, and stated LVN 2 knew what to do if controls were out of range. When the facility was asked for the orientation checklist for LVN 2, the DON stated the facility could not find the orientation checklist for LVN 2 indicating that she had received training on doing glucometer calibration quality control. A review of the undated facility nursing policy and procedure, untitled and undated, provided by the DON, indicated under, ?Policy: It is the policy of the facility to maintain Blood Glucose Control Quality.? In the same policy under, ?Procedure, indicated, "The following steps should be followed to perform a successful quality control test...Perform high control test and compare the result to the expected result range. Document the result on the QC log... NOTE: If test results are out of range, use the backup machine and notify RN supervisor and/or Director of Nurses." The facility failed to follow their policy and procedure for performing quality control testing on the glucometer used to check patient?s blood sugar levels. The accuracy of the glucometer quality control test results was not monitored. As a result, the out of range quality control test results were not reviewed by anyone, which had the potential for inaccurate blood glucose results using the glucometer and nurse administration of incorrect doses of insulin. These facility failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 240000286 |
Rimrock Villa Convalescent Hospital |
240012556 |
A |
1-Sep-16 |
None |
18992 |
REGULATION VIOLATION 72313(a)(2): Nursing Service - Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. During a recertification survey on March 8, 2016, it was determined the facility staff failed to ensure medications were administered without error to five patients (Patients A, B, C, D, and E) as follows: 1. For Patient A, Pepcid (anti-acid) was not administered as ordered by the physician. This failure had the potential to jeopardize the health and safety of Patient A. 2. For Patient B, a Nitroglycerin patch (medication used to treat chest pain by relaxing the blood vessels to allow blood to flow more easily to the heart) was not removed as ordered by the physician. This failure had the potential for the nitroglycerin patch to be ineffective and increase the risk of physical dependence. 3. For Patient C, Insulin (medication that lowers blood sugar levels) was not administered as ordered by the physician. This failure had the potential to place Patient C at risk for extreme blood sugar fluctuations potentially causing serious medical complications or death. 4. For Patient D, a multi-vitamin was not administered as ordered by the physician. This failure had the potential to jeopardize the health and safety of Patient D. 5. For Patient E, pantoprazole (a medication used to decrease the amount of acid in the stomach) was not administered as ordered by the physician, and a physician's order was not obtained prior to administering Norco (a narcotic pain medication). These failures had the potential to jeopardize the health and safety of Patient E. 1. During an observation of the medication pass process on March 8, 2016, at 8:33 AM, a Licensed Vocational Nurse (LVN 1) was observed preparing medications to administer to Patient A. LVN 1 prepared and administered the medications to Patient A. During a review of Patient A's clinical record, the "physician admission orders," dated March 4, 2016, indicated: "2. Pepcid 5 mg (milligrams-a unit of measurement) PO (by mouth) BID (twice a day) 9 AM, 9 PM." During an interview with LVN 1 on March 8, 2016 at 11:25 AM, LVN 1 stated that Patient A received Pepcid 20 MG (four times the ordered dose). LVN 1 stated the Assistant Director of Nurses (ADON) wrote Pepcid 20 MG on the Medication Administration Record (MAR) and that was what she was following. LVN 1 stated she was not sure what the physician's order indicated. LVN 1 stated she depends on the MAR being transcribed accurately because she does not have time to check the physician?s orders for every patient. During an interview with the Assistant Director of Nurses on March 8, 2016, at 12:41 PM, the ADON stated he transcribed Pepcid 5 MG PO BID on the physician admission orders per a verbal order from the physician. The ADON stated he also transcribed Pepcid 20 MG PO BID on the MAR. The ADON stated he did not know why he transcribed Pepcid 5 MG on the physician admission orders and Pepcid 20 MG on the MAR, when the physician's order was Pepcid 5 MG. The ADON further stated that the Pepcid 5 MG was not given as ordered for a total of 3 (three) days and would be considered a medication error. The facility policy and procedure entitled, "Medication Administration," dated last revised April 2, 2013, indicated the following: "Standard: All medications are administered safely and appropriately to help patients overcome illness, relieve/prevent symptoms, and help in diagnosis." 2. During an observation of the medication pass process on March 8, 2016, at 8:59 AM, LVN 1 was observed preparing medications to administer to Patient B. LVN 1 prepared and administered the medication to Patient B. Patient B was sitting up in bed in her room. LVN 1 slightly pulled down Patient B's shirt to place the nitroglycerin patch on her chest. LVN 1 removed a nitroglycerin patch dated March 7, 2016, from Patient B's right upper chest and disposed of it in the bathroom trash can. LVN 1 then dated a new nitroglycerin patch for March 8, 2016, removed the plastic covering, and placed it on Patient B's left upper chest. During a review of Patient B's clinical record, the face sheet (demographics) indicated the Patient B was admitted to the facility on June 18, 2015, with diagnoses that included: coronary artery disease (heart disease), chest pain, and heart failure. A clinical record review of the recapitulation (physician order summary), dated March 1, 2016, indicated "Nitroglycerin Patch 0.2 MG for 12 hours on and off 12 hours transdermal (a route of administration through the skin)." During an interview with LVN 1 on March 8, 2016 at 11:03 AM, LVN 1 stated the nitroglycerin patch should be on for 12 hours and off for 12 hours according to the physician's order. LVN 1 stated the evening shift nurse was responsible for removing Patient B's nitroglycerin patch at 9 PM. The evening nurse [LVN 5] failed to remove the patch at 9 PM, but signed the MAR to indicate she had removed the patch. LVN 1 stated it would be considered a medication error. During an interview with LVN 4 on March 8, 2016, at 11:51 AM, LVN 4 stated she was responsible for Patient B's recapitulations. LVN 4 stated the physician orders indicated nitroglycerin patch on at 9 AM and off at 9 PM. The nitroglycerin patch had been transcribed incorrectly on to the MAR. The MAR indicated, "Nitroglycerin patch 9 AM on and 9 PM on,? instead of 9 PM off. LVN 4 stated, "I missed that.? An interview was conducted with LVN 5, the evening nurse who was responsible for not removing Patient B?s nitroglycerin patch on March 7, 2016 at 9 PM. LVN 5 stated she was in-serviced on the five (5) rights of medication pass (right patient, right medication, right dose, right time, and right route) on March 9, 2016. During an observation on March 10, 2016, at 7:34 AM, in Patient B's room, Patient B was sitting up in her bed watching television. An observation was made of a nitroglycerin patch on Patient B's right upper chest. During an interview with Patient B on March 10, 2016 at 7:35 AM, Patient B stated the nitroglycerin patch was to be placed on at 9 AM, and removed at 9 PM. Patient B stated the evening shift nurse [LVN 5] forgot to remove the nitroglycerin patch. During an interview with LVN 1 on March 10, 2016, at 7:36 AM, LVN 1 stated she did not have an answer as to why the nitroglycerin patch was on Patient B. LVN 1 stated it would be considered a medication error. During an interview with the Director of Nurses (DON) on March 10, 2016, at 12:31 PM, the DON stated she had inserviced LVN 5 the day before (March 9, 2016) on removing the nitroglycerin patch. The DON stated, "I don't know what happened." The facility policy and procedure entitled "Medication Administration," dated last revised April 2, 2013, indicated: "Standard: All medications are administered safely and appropriately to help patients overcome illness, relieve/prevent symptoms, and help in diagnosis." 3. During an observation of the medication pass process on March 9, 2016, at 6:15 AM, in Patient C's room, LVN 2 checked Patient C's blood sugar, then removed the gloves and documented the blood sugar of 361 on the diabetic flow sheet. LVN 2 donned new gloves and administered Lantus (long-lasting insulin) 20 units subcutaneous to Patient C's left lower abdominal area. LVN 2 did not administer Humalog (fast-acting insulin). During an observation on March 9, 2016, at 6:51 AM, in Patient C's room, Patient C was sitting in a wheelchair eating breakfast at the bedside table. Patient C's breakfast included eggs, bacon, potatoes, a bowl of cheerios and milk, blueberry muffin and an apple juice. During a review of Patient C's clinical record, the facesheet (demographics) indicated Patient C was admitted to the facility on October 30, 2015, with a diagnosis of diabetes. A clinical record review of Patient C?s recapitulation (physician order summary), dated February 27, 2016, indicated: "Lantus 20 units Subq (subcutaneous) daily, Accu-checks (blood sugar check) AC (before meals) and HS (bedtime) with Humalog (a fast-acting insulin that works by lowering levels of sugar in the blood; once injected, the insulin takes 30 minutes to work) Sliding scale (insulin doses that are increased in increments corresponding to an increasing range of blood sugar results)subcutaneous as follows: ... greater than 331 give 8 units (a value of measurement) and call MD (Medical Doctor)." During an interview with LVN 2 on March 9, 2016, at 7:23 AM, LVN 2 stated she did not give 8 units of Humalog insulin to Patient C because the diabetic flow sheet did not indicate to give 8 units of Humalog insulin for a blood sugar greater than 331. LVN 2 further advised that the diabetic flow sheet only indicated to call the physician. LVN 2 stated whoever completed the monthly recapitulation should make sure the physician orders and the MAR, including the diabetic flow sheet, are correct. LVN 2 stated she followed the MAR, including the "diabetic flow sheet," and only reviews the physician orders when there are discrepancies, or has any questions regarding the MAR. LVN 2 stated it will be considered a medication error. A clinical record review of the "diabetic flow sheet," dated March 1-31 2016, indicated on March 4, 2016 at 6:30 AM, Patient C's blood sugar was documented as 358 and he received 7 units of Humalog insulin. During an interview with LVN 4 on March 9, 2016, at 7:38 AM, LVN 4 stated that on March 4, 2016 at 6:30 AM, Patient C's blood sugar was documented on the diabetic flow sheet as 358 and he received 7 units of Humalog insulin. LVN 4 stated Patient C should have received 8 units of Humalog insulin per the physician order. During an interview with LVN 6 (who transcribed Patient C?s physician orders on the MAR and diabetic flow sheet), conducted on March 9, 2016, at 1:03 PM, LVN 6 stated she forgot to transcribe the physician order to give 8 units of Humalog insulin for a blood sugar greater than 331 on the diabetic flow sheet. LVN 6 stated she only transcribed on the diabetic flow sheet to call the physician for a blood sugar greater than 331. During a concurrent interview with LVN 6, LVN 6 stated on March 4, 2016, at 6:30 AM, Patient C's blood sugar was documented on the diabetic flow sheet as 358 and he received 7 units of Humalog insulin. LVN 6 stated Patient C should have received 8 units of Humalog insulin per the physician orders. A clinical record review of the "diabetic flow sheet," dated March 1-31, 2016, indicated on March 4, 2016 at 11:30 AM Patient C's blood sugar was 418 and he received 7 units of Humalog insulin. During an interview with LVN 1 on March 9, 2016, at 2:00 PM, LVN 1 stated on March 4, 2016 at 11:30 AM, Patient C's blood sugar was 418 and she administered 7 units of Humalog insulin. LVN 1 stated Patient C should have received 8 units of Humalog insulin per the physician orders. LVN 1 stated she administered 7 units of Humalog insulin to Patient C because that was the maximum dose to give on the diabetic flow sheet. LVN 1 stated she would rather administer some insulin coverage instead of no insulin coverage at all. LVN 1 stated she was not aware that the physician order indicated to administer 8 units of Humalog insulin for a blood sugar greater than 331. LVN 1 stated it was important that the person responsible for monthly recapitulations transcribed it accurately. LVN 1 stated she was dependent on the MAR and diabetic flow sheet to be transcribed accurately because she does not review the physician orders. The facility policy and procedure entitled "Medication Administration," dated last revised April 2, 2013, indicated: "Policy: Responsibility of the nursing professional: be aware of the classification, action, correct dosage, and side effects of a medication before administration." 4. During an observation of the medication pass process on March 8, 2016, at 9:40 AM, LVN 3 was observed preparing medications to administer to Patient D. LVN 3 prepared and administered the medication to Patient D. During a review of sampled Patient D's clinical record, the "physician admission orders," dated February 29, 2016, indicated: "...14. MVI (multivitamin) with minerals 1 tab PO (by mouth) daily 9 AM." During an interview with LVN 3 on March 8, 2016 at 10:58 AM, LVN 3 stated that Patient D did not receive the multivitamin because it had not been transcribed on the MAR and it would be considered a medication error. During an interview with the Assistant Director of Nurses (ADON) on March 8, 2016, at 12:33 PM, the ADON stated he should have transcribed the multivitamin on to the MAR. The ADON stated, "I missed the multivitamin.? The ADON stated, ?Patient 11 has missed several doses of the multivitamin and it will be considered a medication error.? The facility policy and procedure entitled, "Medication Administration," dated last revised April 2, 2013, indicated: "Standard: All medications are administered safely and appropriately to help patients overcome illness, relieve/prevent symptoms, and help in diagnosis." 5. During a review of the clinical record for Patient E, the face sheet (contains demographic information) indicated Patient E was admitted to the facility on April 9, 2015, and re-admitted to the facility on February 12, 2016, with diagnoses which included: chronic obstructive pulmonary disease (COPD- a lung disease characterized by chronic obstruction of airflow that interferes with normal breathing), cerebrovascular accident (CVA-stroke), gastroesophageal reflux disease (GERD- acid reflux into the esophagus). During a review of Patient E's physician's orders, an order dated February 12, 2016, indicated Patient E was to have omeprazole (a medication for GERD) 20 milligrams (mg) daily at 6:30 AM before breakfast. A review of the pharmacy consultation report dated February 23, 2016, was conducted. The pharmacist consultant recommended discontinuing omeprazole and starting pantoprazole (a medication for GERD) 20 mg daily with rationale as follows: Patient E "receives clopidogrel (a blood thinner) and also receives omeprazole since October 10, 2015. Co-administration of these two medications can result in significant reductions in clopidogrel's active metabolite levels and antiplatelet activity. Individuals at risk of heart attacks or strokes, who are given clopidogrel to prevent blood clots, will not get the full anti-clotting effect if they also take omeprazole." A review of Patient E's physician's order, dated March 3, 2016 at 7:15 PM, indicated the nurses were to discontinue omeprazole and begin pantoprazole 20 mg daily. A review of the Medication Administration Record (MAR) for March 2016, indicated that Patient E continued to receive omeprazole from March 4, 2016 through March 9, 2016, after the medication had been ordered to be discontinued. A handwritten note on the MAR indicated to start Protonix (brand name for pantoprazole) 20 mg daily "when it arrives," with an additional post-it note attached to Patient E's MAR, to start Protonix, "when omeprazole is exhausted." During an interview with a licensed vocational nurse (LVN 4) on March 9, 2016, at 6:25 AM, LVN 4 stated that usually the medication comes the same day it is ordered, but it had not arrived at the facility and the nurses would administer the medication when it was delivered. During an interview with an LVN charge nurse (LVN 3) on March 9, 2015, at 7:05 AM, LVN 3 stated that pantoprazole would begin when omeprazole was finished. LVN 3 was unable to find an order to substantiate postponing the discontinuation of omeprazole and starting of pantoprazole. LVN 3 stated that she was aware of the handwritten notes on the MAR, but stated she had not checked the physician orders. LVN 3 stated, "I should have checked the orders, and clarified with the LVN who wrote on the MAR to postpone the order." During a review of Patient E's physician's orders, an order dated August 24, 2015, indicated Norco 5/325 mg (narcotic pain medication) was to be administered every six (6) hours as needed for pain. During a review of the Discharge Summary from the general acute care hospital dated February 12, 2016, the summary indicated instructions for Patient E to stop taking Norco. A review of the physician's re-admission orders, dated February 12, 2016, indicated that Norco was not reordered. A review of the Nurses Weekly Summary, and the Controlled Drug Record (a log where narcotics are counted and signed out prior to administration) reflected that Norco had been given without a physician's order as follows: 1. February 22, 2016, the nurses documented on the Weekly Summary that Norco had been administered for pain. 2. February 26, 2016, a nurse had signed out Norco on the Controlled Drug Record for Patient E. 3. February 29, 2016, the nurse documented on the Weekly Summary that Norco had been administered for pain. During an interview with LVN 6 on March 10, 2016, at 3:30 PM, LVN 6 stated that new orders were supposed to be written for a patient upon re-admission to the facility, even when the patient returned to the facility the next day. LVN 6 confirmed that Patient E was admitted to the hospital on February 11, 2016 and readmitted to the facility on February 12, 2016. She stated the previous orders would be discontinued when new orders were written at the time of re-admission. During an interview with the DON on March 10, 2016, at 3:45 PM, the DON confirmed that Norco was given to Patient E in error and without a physician's order. During a review of facility's policy and procedure entitled, "Medication Administration," dated as revised October 2004, page 12-8, under procedure #17 indicated the following: "PRN (medication given as needed) medication was charted with initials, and time is given in the corner of the box." On page 12-12, in the same policy and procedure dated February 2013, the following was indicated: "A physician order is required for administration of controlled drugs." Under the section of the policy and procedure entitled, "Procedure when the Patient is readmitted from Outside Inpatient Setting," the following was indicated: "1. Upon readmission from a setting outside the nursing home, the nursing home receives physician orders that list medications the patient is to take upon readmission to the nursing home. 2. The admitting charge nurse reviews all available information as well as medications the patient was taking at the nursing home prior to admission to the hospital or other setting and reconciles the medication regime." The facility?s failures, as described, are violations which present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term care facility would result therefrom. |
| 240000047 |
Rialto Post Acute Center |
240012808 |
A |
9-Dec-16 |
7TID11 |
6661 |
REGULTAION VIOLATION: Health and Safety Code 1424 (d): (d) Class ?A? violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. Title 22, California Code of Regulations, Division 5, Chapter 3, Article 3, Section 72311 (a) (2): (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient?s care plan according to the methods indicated. Each patient?s care should be based on this plan. Title 22, California Code of Regulations, Division 5, Chapter 3, Article 5, Section 72523 (a): (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to implement interventions in a patient?s care plan according to methods indicated in the care plan to prevent Patient A?s fall. Specifically, the facility failed to provide a tab alarm (fall prevention device that can be used on wheelchair, chair or bed to alert caregivers when a fall risk patient attempts to transfer/walk/get out of chair/bed unassisted) for Patient A. This type of alarm is clipped to the patient's clothing with a string attached to the clip. If the patient gets up or moves further then the string length, a magnetic connection is broken and an alarm sounds.) Patient A was in bed on October 15, 2016 but did not have a tab alarm as required by the plan of care. Patient A fell out of bed, and as a result sustained a subdural hematoma (bleeding on the brain) and required hospitalization. During an interview with the complainant on October 25, 2016 at 12 PM, she stated Patient A had fallen at the facility on October 15, 2016 at 2 AM. Patient A was sent to the acute hospital on October 15, 2016 at 8 AM and was found to have a subdural hematoma. A review of Patient A's clinical record reflected Patient A was admitted to the facility on September 16, 2016 with diagnoses which included ESRD (end stage renal disease, condition when the kidneys are failing), diabetes mellitus (a condition when there is high level of sugar in the blood), hypertension (high blood pressure), anemia (low red blood cell count) and generalized weakness. A review of the licensed nurse's progress notes dated October 14, 2016 at 8:22 PM documented Patient A was readmitted to the facility for rehabilitation which included physical therapy and occupational therapy. Patient A's readmission diagnoses included dementia (cognitive impairment), anemia and muscle weakness. The progress notes further indicated the physician had agreed to continue with the same plan of care, prior to October 14, 2016. A review of the care plan entitled, "at Risk for Fall," dated September 23, 2016, showed Patient A was at risk for falls related to, "generalized muscle weakness, impaired safety awareness.? Further review of the care plan intervention, documented that a "tab alarm" was to be implemented upon Patient A?s readmission on October 14, 2016. During a review of the licensed nurse's progress notes dated October 15, 2016 at 3:09 AM, the following was documented: "I charge nurse (LVN 1) was preparing to begin my charting at 2:00 AM when I heard a loud bang come from the [patient's] room. When I went to patient's room I found the patient lying on the floor on his left side near the closet." Further review of the nurse's note, showed there was no documented evidence a tab alarm was in place when Patient A fell. An interview was conducted with LVN 1 on October 26, 2016 at 2:18 PM. LVN 1 stated Patient A did not have a tab alarm in place when he fell on October 15, 2016. When asked why Patient A did not have the alarm on at the time of the fall, LVN 1 responded, "I did not get around to it." An interview was conducted with the Registered Nurse (RN 1) on October 26, 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 October 15, 2016. RN 1 stated she did not hear or see a tab alarm when Patient A fell. RN 1 further stated that all patients are to have a tab alarm placed for three to seven days after admission or readmission to the facility. A review of the facility policy and procedure entitled, "Alarms," dated June 15, 2015, indicated the purpose of the policy as follows: "To alert staff of unassisted transfers...To minimize risk of falls associated with unsafe transfer attempts." During an interview with the Director of Nurses (DON) on October 26, 2016 at 4:45 PM, she confirmed that all patients that are admitted or readmitted to the facility are to have a tab alarm in place for three to seven days to help prevent falls. The DON stated Patient A should have had a tab alarm in place when Patient A was readmitted to the facility on October 14, 2016. A review of the, "Neurological Assessment" form for Patient A, dated October 15, 2016, indicated pupil size assessment was at 5 between 2:30 AM to 6:10 AM, and that Patient A?s pupils were reactive to light (Pupils constrict when light shown in the eye). At 7:10 AM, the patient's pupil assessment was increased to 6 and non- reactive to light. An interview was conducted with LVN 1 on October 26, 2016 at 2:18 PM. LVN 1 stated on October 15, 2016 between 7-7:30 AM, he found Patient A was non responsive (unable to awaken) with pupils at 6, and non- reactive to light. Patient A was transferred to the hospital. A review of the "Death Summary,? from the acute hospital dated October 26, 2016, documented the following: "Traumatic (brain dysfunction caused by an outside force, usually a violent blow to the head) brain injury and subdural hematoma." A review of the "Record of Death," (undated) from the acute hospital, documented the following: "[Patient A] expired (died) xxxxxxx at 7:50 AM from brain death (a condition when there is no brain activity to sustain life). The facility failed to implement and provide a necessary intervention for Patient A and failed to prevent Patient A?s fall by failing to provide a tab alarm when Patient A was in bed on October 15, 2016. Consequently, Patient A experienced a fall on October 15, 2016, sustained a subdural hematoma (bleeding on the brain) and required hospitalization. These violations presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 240000013 |
RANCHO MESA CARE CENTER |
240012912 |
A |
27-Jan-17 |
I99611 |
6236 |
REGULATION VIOLATION: 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to implement policies and procedures for the safe utilization of equipment and supportive devices to transfer a patient from a wheelchair to a bed. Specifically, the facility failed to ensure the Hoyer lift sling (a supportive device that is used with a mechanical lift) was safe to use for the transfer of Patient A from a wheelchair to a bed. This failure resulted in Patient A's fall from the Hoyer lift sling onto the floor, and resulted hip and pelvis fractures and hospitalization of Patient A. A review of Patient A's clinical record, reflected Patient A was admitted to the facility on XXXXXXX with diagnoses which included hypertension (high blood pressure), diabetes (high blood sugar), and hemiplegia (unable to move one side of the body). A review of the history and physical, completed by the physician on April 22, 2016, indicated Patient A does not have the capacity to understand and make her own decision. A review of the Resident Assessment Instrument (RAI-a facility comprehensive assessment tool) functional status (the measure of a person's ability to perform Activities of Daily Living (ADLs such as bed mobility, toileting, personal hygiene,etc) dated November 1, 2016, indicated Patient A required staff assistance with all her ADLs. Patient A was non ambulatory. A review of the licensed nurse's progress notes, dated November 24, 2016 at 10:15 PM, reflected Patient A was noted to be grimacing and crying after a fall. Specifically, the progress note set forth the following: "Patient [A] was being transferred from the wheelchair to the bed via hoyer lift...both CNA (Certified Nursing Assistant) states that the sling broke from one support loop supporting the lower extremities. Patient [A] ascended down on both legs and rested onto the left side...Nurse contacted 911 immediately...Patient [A] transported to hospital." Patient A was not in the facility during the investigation. During an interview with the Licensed Vocational Nurse (LVN 1) on December 6, 2016 at 4:45 PM, he stated after the incident on November 24, 2016 every Hoyer lift sling in the facility were checked and found 4 (Four) slings were torn after tugging the straps and the support loops. They were all removed from the floor. During an interview with CNA 2 on December 6, 2016 at 5:30 PM, she stated on November 24, 2016 she assisted CNA 1 to transfer Patient A from the wheelchair to the bed using the hoyer lift. CNA 2 stated during the transfer she heard a tear from the hoyer sling. She had noticed the hoyer lift sling was torn. Patient A fell hard on the left side landing on the metal support base of the Hoyer lift. During an interview with the Administrator on December 6, 2016 at 6 PM, she stated prior to the incident the facility did not have any policy in place on how to ensure the Hoyer lift slings are safe to use to transfer the patients using the Hoyer lift. During an interview with the Certified Nursing Assistant (CNA 1) on December 7, 2016 at 6:30 PM, she stated on November 24, 2016, she was assigned to take care of Patient A. She stated at approximately 7 PM, Patient A was up in the wheelchair with a hoyer lift sling underneath her. Patient A was put on the wheelchair by CNA 3. CNA 1 stated she asked CNA 2 to help transfer Patient A from the wheelchair to the bed with the Hoyer lift. CNA 1 stated while she was lifting Patient A from the wheelchair to the bed using a Hoyer lift, she heard a tear from the Hoyer lift sling. CNA 1 stated she noticed the Hoyer lift sling tore from the strap loops from the Hoyer lift. Patient A fell out of the sling onto the floor. CNA 1 was asked if she had checked the straps and the strap loops prior to transfer the patient, she responded "No. The sling was worn out, it looks old. We kept using it over and over again. I assumed the sling was safe." CNA 1 stated she should have checked the sling straps and strap loops prior to transfer the patient. CNA 1 stated prior to the incident she had not been in serviced on how to inspect the Hoyer lift sling that included checking the straps and the support loops. CNA 1 stated Patient A required a Hoyer lift transfer. CNA 3 was not available to be interviewed during the investigation. During an interview with the Director of Nursing (DON) on December 7, 2016 at 6:50 PM, she stated there was no system in place that included checking the strap and strap loops to ensure the Hoyer lift slings are safe to use to transfer the patients using the Hoyer lift prior to the incident on November 24, 2016. During a review of the in-service record on December 7, 2016 at 7 PM, at the Director of Staff Development's office, showed there was no record of in-service had been provided to the staff on how to inspect the Hoyer lift sling prior to the incident. The Director of Nursing (DON) verified the finding at the time of document review. A review of the Hoyer lift sling manufacture "Instruction Manual" indicated "Carefully inspect the sling before each use for wear and damage to seams, fabric, straps and strap loops...Use only slings that are in good condition. Discard and destroy old...slings" During an interview with the complainant on December 8, 2016 at 3:45 PM, the complainant stated Patient A had fallen from the Hoyer lift sling at the facility on November 24, 2016 at approximately 7:30 PM. Patient A was sent to the acute hospital where Patient A was found to have hip and pelvis fractures. A review of the x-ray result from the acute hospital, dated November 24, 2016, indicated Patient A sustained left hip and pelvis fractures. The failure of the facility to implement policy and procedure for the safe transfer of patients from a wheelchair to a bed utilizing a Hoyer lift is a violation which has presented imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. |
| 250000081 |
RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC |
250008778 |
B |
18-Jan-12 |
7MT911 |
3851 |
1. Title 22- 72527(a) (9) (a)-Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9)-To be free from mental and physical abuse. The facility failed to protect Patient A from physical abuse when CNA 1 hit the patient in the back of the head with a clipboard. The facility self reported an incident on August 22, 2008, which read, "CNA ___ (name) allegedly hit resident with a clipboard. No injuries. Investigation pending. CNA suspended." A review of Patient A's medical record was conducted on August 25, 2008. Patient A was admitted to the facility on March 27, 2008, with diagnoses of schizophrenia (mental disorder), hypothyroidism (low thyroid hormone), and hypertension (high blood pressure). Patient A was described on the Minimum Data Set (MDS), an assessment tool and dated July 3, 2008, as having moderate cognitive impairment but had no short and long term memory deficits. Patient A required oversight supervision with bathing, and personal hygiene, and independent with eating, and dressing. An entry on the Nurse's Notes on August 22, 2008, at 1:15 p.m., read, "Res (resident) on (sic) neurocks (neurochecks) q4 hr (every 4 hours) x 3 days d/t (due to) bump on head." On August 25, 2008, at 2:35 p.m., the Director of Nursing (DON) was interviewed. The DON stated that she received a call from the Charge Nurse (CN) on August 21, 2008, at 6:20 p.m., stating the housekeeper reported that Certified Nursing Assistant (CNA 1) hit Patient A on the head with the clipboard. She told the CN to instruct CNA 1 to clock out, go home, and not to return to work unless notified. On August 25, 2008, at 3:50 p.m., Patient A was interviewed. Patient A was alert but confused. He stated, "My name is April till the day I die. I'm doing fine." On August 26, 2008, at 11:40 a.m., the housekeeper was interviewed. The housekeeper stated that on August 21, 2008, at 6 p.m., she was walking down to the lobby, when she saw Patient A grabbing the food from the tray cart, and CNA1 hit Patient A on the back of the head with the clipboard. While in the break room, the housekeeper asked CNA 1, why she hit Patient A on the back of the head with the clipboard? CNA 1 stated, "It was a quick reaction." On August 26, 2008, at 11:50 a.m., the Dietary Staff (DS) was interviewed. The DS stated she was by the kitchen window, when she saw Patient A grabbing the food from the tray cart, and put the food in the mouth while leaning forward. The DS stated that Patient A was leaning forward when CNA1 grabbed Patient A on the arm, and hit the patient's back of the head with the clipboard. On August 26, 2008, at 1:35 p.m., CNA 4 was interviewed. CNA 4 stated that Patient A had a behavior of getting food from other patients. CNA 4 stated, "He (Patient A) has always been that way."On September 2, 2008, at 10:45 a.m., CNA 5 was interviewed. CNA 5 stated that Patient A grabbed food from the food cart's tray after putting the tray in the food cart after meals.CNA 6 was interviewed on September 2, 2008, at 10:51 a.m. CNA 6 stated that Patient A grabbed food from the other patients' tray from time to time. CNA 6 stated that Patient A would grab food from the tray cart when putting the tray after meal.Therefore, the facility failed to protect Patient A from physical abuse when CNA 1 hit the patient in the back of the head with a clipboard. The above violations either jointly, separately, or in any combination had a direct or immediate relation to Patient A's health, safety, or security. |
| 250000073 |
Riverside PostAcute Care |
250009024 |
B |
23-Feb-12 |
D58R11 |
7557 |
(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 make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The facility failed to ensure a patient was free from abuse. The facility failed to ensure that Patient A's right to be free from mental abuse was not violated, as evidenced by the facility's failure to prevent CNA 1 (Certified Nursing Assistant) from threatening Patient A, which had caused anxiety and fear to Patient A The facility failed to ensure that CNA cared for Patient A by emptying the bedpan when asked to do so by Patient A. The facility did not ensure that CNA 1 did not ask for food and drinks that belonged to Patient A. On August 12, 2010, during an unannounced visit to the facility to investigate an entity reported incident or complaint, a review of Patient A's medical record was conducted. Patient A was admitted to the facility on July 26, 2010 with diagnosis that included diseases of the heart and inability to sleep.The minimum data set (MDS) assessment dated March 19, 2010, showed that Patient A had no memory problem and was independent with decision-making. During an observation and interview on August 12, 2010, at 3:45 p.m., Patient A was in a wheelchair, in her room, awake and able to answer questions. Patient A stated that CNA 1, who worked on the night shift (11 p.m. - 7 a.m.), had been her nurse. Patient A expressed "dissatisfaction with (name) CNA 1's performance that she (CNA 1) would not clean my (Patient 1) bedpan". Patient A demonstrated an excellent vocabulary of the English language, as evidenced by her choice of words as she described her feelings of fear and anxiety. Further review of Patient A's admission record indicated that she was a Paralegal. Patient A said she had her personal snacks and soda drinks in her room, CNA 1 had been asking her for snacks and soda drinks while working on the night shift. Patient A explained that since CNA 1 appeared to be always tired, she had been giving CNA 1 her personal snacks and drinks when she asked for it. Patient A stated that during one of the meetings (Patient was unable to recollect the exact date and time) she had with the Administrator and Social Service Designee (SSD), she told them that CNA 1 had been asking her for her personal snacks and drinks when she (CNA 1) worked on the night shift.Patient A said four CNAs (CNAs 2, 3, 4, and 5) had told her that she (CNA 1) was heard bragging about confronting the patient. The CNAs told Patient A that CNA 1 was "furious and would get back at me (Patient A)". Patient stated that she "felt threatened and was fearful that she (CNA 1) would retaliate and physically harm me". Patient A stated, on an evening before the 11-7 shift began (Patient unable to recollect the exact date and time), she had called the DON (Director of Nursing) and reported her concern about her fear of the potential threat and harm from CNA 1 when she would come to work. Patient A was not able to talk with the DON and had left the message on the DON's mobile phone. The DON never returned call or investigated Patient A's complaint.Patient A stated on the night shift of August 10, 2010, CNA 1 went back into her room, had woken her up and verbally confronted her about the patient's action of reporting her (CNA 1) for asking snacks and soda drinks from her (Patient A). Patient A stated that she felt threatened and frightened by the presence of CNA 1 during that night. Patient A was sent out to the hospital later that day (August 10, 2010). Patient A stated she had reported the incident to the administrator and the SSD on August 9, 2010, and that the administrator had told her that he (Administrator) would investigate her complaint. The Administrator had assured Patient A that CNA 1 would "Never step foot in this station again."Patient A stated she was "surprised and alarmed", when she learned that she (CNA 1) was allowed to work on the night shift on August 10, 2010, despite the reassurance made by the administrator that she (CNA 1) would be suspended pending the investigation result.During an interview with the SSD, on August 12, 2010, at 3:16 p.m., the SSD stated there was a general in-service regarding "Appropriate Behavior/Accepting and Soliciting" that was given by the director of staff development (DSD) on August 6, 2010. The SSD stated that CNA 1 "apparently took (the in-service) personally". The SSD further stated that because Patient A offered people snacks, the facility did not consider the issue as reportable to the state agency.During a telephone interview with CNA 2, on August 13, 2010, at 8:08 a.m., she stated the following: CNA 2 was not sure of the date and time when CNA 1 asked what Patient A had told the administrator.CNA 2 told CNA 1 that Patient A had told the administrator that CNA 1 had left Patient A's bedpan dirty, and that CNA 1 had also asked Patient A for sodas and nuts. CNA 1 stated, "I'm gonna go after her, I never asked her nothing".CNA 1 went to Patient A that night and "confronted or approached her (Patient A)."CNA 1 was put back to work in another station, after the complaint was filed. On August 13, 2010, a review of the Employee Warning Record showed that the administrator had suspended CNA 1 from working, effective "Immediately (on August 9, 2010) pending investigation result." A review of the daily staffing sign in and out sheets and the electronic time sheets with the assistant staffing personnel showed that CNA 1 had continued to work on the 11-7 shift on August 10, 2010 (shift started August 9 at 11 p.m. and ended August 10 at 7 a.m.) A review of an undated facility abuse policy and procedure showed the following:"...Any staff member that is suspected of abuse will be suspended while the investigation is conducted. The staff member will not be allowed in the facility while the investigation is in progress." On August 12, 2010, at 1:30 p.m., during an interview with the administrator, he reviewed CNA 1's employee file and stated that he was still investigating the complaint regarding allegation of abuse reported by Patient A. The administrator stated that CNA 1 had been suspended and was removed from the schedule completely. However, the administrator stated that CNA 1 had continued to work on the 11-7 shift on August 10, 2010. On August 13, 2010, at 1:30 P.M., the administrator reviewed the daily staffing sign in and out sheets and the electronic time sheets. The records showed that CNA 1 was allowed to work after being suspended. The administrator acknowledged that CNA 1 should have not been allowed to work after being suspended. The facility failed to ensure Patient A was not verbally abused and verbally threatened by CNA 1, by allowing CNA 1 to continue working with patients, including Patient A, after being suspended, thereby subjecting Patient A to mental anguish and fear. The facility failed to implement their abuse policy and procedure by failing to ensure CNA 1 was suspended from work, effective August 9, 2010, as CNA 1 continued to work the night shift on August 10, 2010. The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 250000021 |
RIVERSIDE BEHAVIORAL HEALTHCARE CENTER |
250009109 |
A |
14-Mar-12 |
H63A11 |
7976 |
CLASS A CITATION-ACCIDENTSTitle 22 - 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. On April 2, 2010, an unannounced visit was made to the facility to investigate an entity reported incident which resulted in Patient A having his right middle finger amputated. Based on observation, interview, and record review, the facility failed to ensure Patient A was evaluated on a continuing basis by failing to assess the patient's bandaged right middle finger. This failed practice led to Patient A developing gangrene (tissue death due to a lack of blood supply,) necessitating an amputation after the patient placed a rubber band around his right middle finger and covered it with a band aid and tape. A review of Patient A's record was conducted. Patient A was admitted to the facility on September 13, 2007, with diagnoses of schizophrenia (mental health illness,) and hypothyroidism (low levels of thyroid).A review of the Interdisciplinary Team Notes, dated March 29, 2010, at 10:15 a.m., was conducted on April 2, 2010. LPT 1 (licensed psychiatric technician) indicated, "Noted client to have rubber band & tape around right middle (finger) very tight. Tape & rubber band removed. Finger swollen & scant amount bleeding. Dr, (Physician A,) notified, - order to send to ER (emergency room) for eval. (evaluation,) & treatment. To send by ambulance (with) staff escort. ER notified, EMR (emergency medical response,) notified..."The radiology report from the emergency room, dated March 29, 2010, revealed "tourniquet-like narrowing at the base" of the patients right middle finger.A review of the emergency room record, dated March 29, 2010, at 10:51 a.m. indicated Patient A was evaluated for an ischemic digit with gangrene (tissue dying on the finger). Under "History of Present Illness" the patient's chief complaint was listed as "Injury to the right hand and right middle finger. The injury happened 2 weeks ago patient started to wrap his finger and would not let anyone at the...facility look at it. Today they finally noticed that it was discolored and had a tight rubberband around the proximal (lower) part of his finger." There was no surgical intervention at that time, until the extent of the injury could be determined. The patient was discharged back to the facility on March 29, 2010, at 3:05 p.m., with orders to closely monitor the finger and a prescription for antibiotics.The Physician Progress Record, dated March 30, 2010, revealed "Has gangrene ...Pt (Patient) ligated (tie-off with) band ? (unknown) duration. Digit (finger) is gangrenous (dead tissue)." The Interdisciplinary Team Notes, dated March 31, 2010, (not timed), PC 1 (primary counselor) indicated, "Res. (Patient A,) was asked where he got gauze, bandages, white tape from, he stated from nurses..."In the Interdisciplinary Team Notes, dated April 2, 2010, at 11:45 a.m., the RN (registered nurse) documented, "When asked when this happened, I then began to back track each day with (Patient A,) starting with Tuesday 3/30/10, Monday 3/29, Sunday 3/28, Saturday 3/27, and stopping at Friday 3/26, when (Patient A,) then stated, 'Yes, that Friday'. I then asked, does that mean you had your finger rubber band for 3 days, and he said, 'Yes'."An interview was conducted with LVN 3 (licensed vocational nurse) on April 2, 2010, at 2 p.m. When questioned whether a rubber band was considered an item which is prohibited or regulated in the facility, LVN 3 stated patients could have rubber bands, they are not a restricted item. On April 2, 2010, Patient A went to the acute care hospital and had an amputation of his right middle finger. He returned to the facility on April 3, 2010. The Interdisciplinary Team Notes, dated April 5, 2010, at 2:30 p.m., were reviewed. PD 1 (program director) indicated, "...I asked Client (Patient A,) to tell me what happened. Client stated 'I hurt my finger playing football.' I asked Client what he did after that. He stated 'I went to bed.' I asked him if he had told the nurse. Client stated, 'No, I went to the nurse the next day and she gave me some band aids. 'I asked Client about the rubber band. Client stated 'my finger was hurting so I put the rubber band on and the band aids and tape to make it feel better'..."An interview was conducted with MHW 1 (mental health worker) on April 2, 2010, at 1:45 p.m. MHW 1 stated, "I noticed it on Monday, March 29th, when (Patient A,) grabbed for a cigarette during the first smoking break, he had adhesive tape around his right middle finger. (Patient A,) said he hurt it playing football, and then he said he hurt it three weeks ago. I took off the band aid, it was dripping blood. (LVN 1, licensed vocational nurse) cut the tape, we saw the rubber bands, the finger turned black...I saw it at 9:45 (a.m.) during the first smoke break."An observation and interview were conducted with Patient A on April 7, 2010, at 11:50 a.m. Patient A was observed with dressings covering his right hand and arm. When interviewed, Patient A stated, "I had the rubber band on a couple of days, I hurt it playing football in a friends room with a sock, I put the rubber band on and covered it with three band aids and a clear tape, it didn't hurt." Review of the facility policy, "Change of Condition Management Guideline," was conducted on April 7, 2010. The purpose indicated, "The purpose of this guideline is to ensure that resident's change of health condition is assessed timely, appropriate intervention implemented, the effectiveness of intervention, evaluation, etc., to ensure the highest quality of care. Definitions: Change of Condition: A change of condition may be subtle and slow to develop, severe and develop quickly, and physical, mental and/or psychosocial in nature..." The procedure indicated, "The licensed nurse will conduct assessment of resident's health status in determining if the condition is life threatening or not."An interview was conducted with LVN 1 on April 30, 2010, at 3 p.m. LVN 1 stated, "If a patient asks for a bandage we usually bring the patient into the nursing station to assess the problem, we assess the patient first." An interview was conducted with LVN 2 on May 13, 2010, at 10:30 a.m. LVN 2 stated, "If any resident asks for a band aid, we would have brought him to the station and assessed him."Record review failed to show that Patient A received an assessment prior to procuring the band aid or the tape, or after the band aid and the tape was placed on his right middle finger. A review of the informed consent dated March 31, 2010, for the right third middle finger joint disarticulation, indicated surgical risks included, pain, scar, infection, bleeding, neurovascular damage, the need for further intervention (including surgery), loss of function and deformity.Patient A had a right surgical amputation of his right middle finger, on April 2, 2010, four days after the rubber band, the band aid, and the tape were observed on the patient's right middle finger due to ischemia (loss of blood flow) and gangrene.Therefore, the facility failed to ensure Patient A was assessed on a continuing basis. This failed practice led to Patient A's developing gangrene, necessitating an amputation of the right middle finger when the patient placed a rubber band around his right middle finger and covered it with a band aid and tape. 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. |
| 250000081 |
RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC |
250009731 |
B |
07-Mar-13 |
6DO311 |
3645 |
Title 22 - 72527 Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The facility failed to protect Patient A from the facility staff's physical abuse. The facility self-reported an incident on July 11, 2009, that Patient A was grabbing for another patient's food; the Certified Nursing Assistant (CNA) then slapped the patient's arm with an open hand. On July 22, 2009, at 10:32 a.m., an interview with the Director of Nursing (DON) was conducted. The DON stated the following: She received a call from the charge nurse that the facility staff slapped Patient A on the arm. She told the charge nurse to send CNA 1 home. On July 13, 2009, the investigation regarding the incident was completed. Patient A had the behavior of grabbing food from other peers. During snack time, Patient A was grabbing other peer's food, when CNA 1 slapped Patient A's arm in front of the charge nurse. On July 14, 2009, CNA 1 was terminated. On July 22, 2009, at 11:30 a.m., an interview with the Activity Director Assistant (ADA) was conducted. The ADA stated the following: Patient A was in and out of the room during movie activity. Popcorn was passed to the patients attending the activity. She did not witness the actual physical contact between CNA 1 and Patient A as the charge nurse blocked her line of sight, but the ADA saw a look of disappointment on CNA 1 and the charge nurse's face. On July 22, 2009, at 3:15 p.m., an interview with the charge nurse was conducted. She stated the following: During the movie and popcorn activity, Patient A tried to take popcorn away from other patients. Patient A walked over to one of the peers and took the peer's snack. CNA 1 walked over and slapped Patient A's arm twice to keep the patient from grabbing other patient's snack. The charge nurse asked CNA 1, if she just hit Patient A. CNA 1 responded, "Yes, but I did not mean to." On July 22, 2009, at 3:30 p.m., an interview with Patient A was conducted. Patient A was asked if the facility staff hit the patient in any way. Patient A responded, "Yes, all of them (staff) hit me," showing both arms to the surveyor. There were no bruises or scratches noted on Patient A's arms. On July 22, 2009, the record for Patient A was reviewed. Patient A was admitted to the facility on April 8, 2008, with diagnoses that included schizoaffective (combination of symptoms such as hallucinations or delusions and depression) disorder. The current MDS (Minimum Data Set), an assessment tool, dated July 16, 2009, indicated Patient A had no short and long term memory deficits, and the cognitive skills for daily decision making was moderately impaired. Patient A had behavioral symptoms that included wandering (moving with no rational purpose, seemingly oblivious to needs or safety). The entry in the "Nurse's Notes," on July 11, 2009, at 4 p.m., read, "...A female staff approached this resident and lightly slapped her on the arm in an attempt to redirect her...staff stated it was an accident..." The facility failed to: 1. Protect Patient A from the facility staff's physical abuse. The above violation either jointly, separately, or in any combination had a direct or immediate relation to Patient A's health, safety, or security. |
| 250000141 |
RAMONA REHABILITATION AND POST ACUTE CARE CENTER |
250010019 |
B |
25-Jul-13 |
778Q11 |
2917 |
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 the allegation of abuse of Resident 1 by a Physical Therapist (PT 1), as reported by Resident 1 to facility staff on December 7, 2012, at approximately 10 a.m., to the California Department of Public Health (CDPH) immediately, or within 24 hours.On January 2, 2013, at 1:45 p.m., the Administrator was interviewed. The Administrator stated the report had been screened by a professional (the Director of Nursing), and reporting was determined to not be required, under the exceptions to reporting. The Administrator stated that, upon review, the Administrator decided it should be submitted and reported the allegation of abuse to the CDPH office on December 18, 2012, at 9:01 p.m. (11 days after the facility became aware of the allegation of abuse).On January 2, 2013, the record for Resident 1 was reviewed. Resident 1 was admitted to the facility on November 30, 2012, and discharged from the facility December 13, 2012. The physician orders indicated an order, dated December 1, 2012, at 11 a.m., for physical therapy five times a week.On January 2, 2013, at 2:45 p.m., an interview was conducted with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated Resident 1 reported, on December 7, 2012, to LVN 1, "I was down in therapy and needed to go to the bathroom and had told a gentleman...He told me, 'Did you go already? Well, let me check.' And he stuck his finger down...and played with her genital area." LVN 1 asked for clarification, and Resident 1 stated, "He checked me there." LVN 1 stated she then reported the allegation of abuse to administration. On January 2, 2013, the facility policy, titled "Abuse Prevention, Intervention, Investigation & Crime Reporting Policy," indicated, "The facility Administrator, or designee, will immediately, or as soon as practically possible with 24 hours of receiving an allegation or forming a suspicion, report the instance of abuse...to the Department of Health Services (or appropriate state agency) as required by law." The facility failed to report the allegation of abuse of Resident 1 by a Physical Therapist immediately, or within 24 hours, and failed to implement the policy, "Abuse Prevention, Intervention, Investigation & Crime Reporting Policy." The facility initially reported the alleged incident of abuse to the CDPH office on December 18, 2012, at 9:01 p.m. (11 days after the facility became aware of the allegation of abuse). These failures placed all residents at the facility in potential danger due to the risk for abuse. These violations had a direct relationship to the health, safety, or security of the residents. |
| 250000073 |
Riverside PostAcute Care |
250010389 |
B |
23-Jan-14 |
QJFZ11 |
7225 |
F223-Free From Abuse/Involuntary Seclusion CFR 483.13 (b) CFR 483.13 (c) (1) (i) 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 resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility failed to ensure Patient 1 was treated with dignity and respect while getting assistance from staff to use the restroom on September 18, 2013. The facility failed to ensure Patient 1 was free from physical abuse while getting assistance from staff to use the restroom on September 18, 2013. A record review was conducted on Patient 1 on September 24, 2013.The record indicated Patient 1 was admitted to the facility with diagnoses of COPD (coronary obstructive pulmonary disease- fine structures of the lungs not exchanging air properly), emphysema (disease of the lungs marked by an enlargement of the air spaces resulting in labored breathing). An interview was conducted with Patient 1's daughter on September 24, 2013, at 12:45 p.m. The daughter stated "Mom has a significant bruise on the left wrist. The daughter further stated... " Mom said that she had to go to the bathroom she had her arm up and the girl (Certified Nursing Assistant-CNA 1] grabbed her left arm and pulled her towards the bathroom." The daughter stated, " She (Patient 1) said, it hurt her and would not have complained but the roommate said she needed to complain." The daughter communicated that her mother was primarily at the facility for respite care, and remains on hospice at a nearby board and care. An interview was conducted with Patient 1's roommate, Patient 2 [Name Withheld] on September 24, 2013, at 10:50 a.m.Patient 2 stated, " (Patient 1) was being assisted out of the bathroom and the CNA 1[Name Withheld] grabbed (Patient 1's) arm in a downward motion to the bed. " Patient 2 added that Patient 1 continued to say, "You ' re hurting me." "There were two bruises later on." Patient 2 further stated, " All day (Patient 1) kept saying, " She hurt me." Patient 2 stated, "I don't want to see anyone else hurt...everyone else (here) treats me good except her (CNA 1)." An interview was conducted with Patient 1's caretaker at the board and care on September 27, 2013, at 4:45 p.m. The caretaker stated, " She (Patient 1) told me that when she was at that facility ... the nurse jerked her out of bed by her arms." The caretaker added that this was one of the first things Patient 1 told her when she arrived at the board and care. A record review was conducted of Patient 1 ' s Minimum Data Set (MDS-a comprehensive assessment of a patient) dated July 27, 2013, page 8, indicated, Patient 1 did not have any long term or short term memory problems. The form further indicated under " Cognitive Skills for Daily Decision Making, " Patient 1 was independent with making decisions regarding tasks of daily life. At the board and care facility, an observation and interview was conducted with Patient 1 on September 27, 2013, at 4:30 p.m. Patient 1 stated, "One particular person pulled me out of bed by my arm...I told the nurse who did it " Oh...you hurt my arm." Patient 1 presented her left arm to the surveyor. Patient 1 was alert and able to make her needs known. At this same time, an observation was conducted of Patient 1's left forearm (lower arm). Patient 1 had two bruises present on the outer aspect of the lower arm. The distal bruise (farther away from the heart) on the left forearm measured one inch long by one inch wide. The proximal bruise (closest to the heart) measured one and one half inch long by one half inch wide. This observation was conducted 9 days after the incident. A record review was conducted on Patient 1 on September 24, 2013. Patient 1's care plan dated September 13, 2013 did not have any entry relating to the alleged incident that was reported by Patient 1's roommate on Friday, September 20, 2013. A record review of the Administrator's written statement to the Department, dated September 24, 2013, indicated, Patient 2 reported CNA 1 "was frustrated and pulling on (Patient 1's) arm, hurting her and yelling her to stop getting up and down." The report further stated..."our investigation found that (CNA 1) was inappropriate in her care and service to (Patient 1). She did cause pain to the resident by pulling on her arm, resulting in bruising." During an interview on December 10, 2013, at 1 p.m., the administrative staff stated the following: 1. Patient 1 has a daughter (another) who resides in the facility and was observed by staff pulling on Patient 1 ' s arm ...the DON stated she (the relative) would attempt to get her out of bed or lead her to different areas of the facility. 2. There was a discrepancy with the answers from those interviewed as to whether Patient 1 was pulled up from the bed or pulled down from the bed. Patient 1 was not a reliable source. 3. Patient 1 had multiple skin issues on admission, had two falls and was on medication that had the potential for this resident to bruise easily with her stay at the facility which may have contributed to the bruises on the left forearm. There was no mention of this information (resident to resident contact) by the facility staff members during the HFEN investigation, prior to the December 10, 2013, interview and record review. There was no documentation in the medical record or a care plan that reflected this occurrence. There was documentation regarding skin tears and bruising with the admission skin assessment. There was not an updated skin assessment clarifying the new bruises to the left lower forearm. Patient 1 ' s record had a physician ' s order for monitoring bruises to the bilateral upper extremities daily for 14 days, dated September 13, 2013. There was no documented evidence that the nurses re-evaluated Patient 1 ' s skin status in their notation with the new bruises or document on the care plan about the new bruises. A review of the undated facility policy and procedure titled, "Prohibition of Abuse, Neglect, Mistreatment and Misappropriation of Resident Property," indicated, under policy statement, "Resident must not be subjected to abuse by anyone, including but not limited to; community staff other residents, consultants, or volunteers, staff of other agencies serving the residents, family members, visitors, legal guardians, friends or individuals." The policy further indicated, under Executive Director/designee, " 5. The Executive Director/designee identifies events such as suspicious bruising or residents, occurrences, patterns, and trends that may constitute abuse: and to determine the direction of the investigation. " The facility failed to ensure Patient 1 was by treated with dignity and respect on September 18, 2013, when CNA 1 pulled on Patient 1's arm causing pain and bruising to the left lower forearm. The facility failed to ensure Patient 1 was free from physical abuse on September 18, 2013, when CNA 1 pulled on Patient 1's arm causing pain and bruising to the left lower forearm. The above violation had a direct or immediate relationship to the health, safety, and security of patients. |
| 250000141 |
RAMONA REHABILITATION AND POST ACUTE CARE CENTER |
250010485 |
A |
21-Feb-14 |
FY2311 |
6349 |
72339 Dietetic Service-Therapeutic Diets Therapeutic diets shall be provided for each patient as prescribed and shall be planned, prepared and served with supervision and/or consultation from the dietitian. Persons responsible for therapeutic diets shall have sufficient knowledge of food value to make appropriate substitutions when necessary. The facility failed to ensure Patient A was served a mechanical soft diet that was prescribed by the physician.On March 20, 2009, the complainant reported the following incident: Patient A was admitted to the facility for rehabilitation of the lower extremities; Patient A did not have any teeth and required a modified diet; Staff served a regular diet, for the lunch meal, to Patient A on March 18, 2009; Patient A choked and 911 was called; Patient A was transferred to the acute care hospital, is unresponsive and dependent on a ventilator. The facility did not report this incident to the Department. On April 21, 2009, an unannounced visit was conducted to initiate the investigation of a complaint alleging substandard care. Patient A's record was reviewed. Patient A, age 83, was admitted to the facility on March 4, 2009. Diagnoses included cerebral vascular accident (stroke), status post fall, weakness and Alzheimer's disease (progressive memory loss). On April 4, 2009, the physician ordered a mechanical soft diet with no added salt. Documentation on the MPN (Multidisciplinary Progress Notes), dated March 18, 2009, at 12:20 p.m., indicated, "[CNA 1] noted resident choking. Called for help. [CNA 1] started Heimlich maneuver (a technique applied to remove a foreign body such as food from the mouth area where it is preventing air flow to and from the lungs) 4 to 5 thrusts given some meat noted to come out...said hello on command...still appeared in distress. Transferred to room...still breathing at the time...stopped breathing, no pulse noted, CPR (cardio-pulmonary resuscitation) initiated, [oxygen] applied via ambu bag (a device used to provide ventilation, breathing, for a patient who is not breathing)." On March 18, 2009, at 12:35 p.m., LVN 2 documented a late entry on the MPN and indicated, "Resident brought back from the dining room in [wheelchair] still unable to breathe. Called 911 and code blue (a code alerting staff to a medical emergency). CPR started...saw food in mouth and able to pull it from mouth. [Continue] CPR, EMT [Emergency Medical Technicians] arrived in 5 [minutes] and [continued] CPR." Documentation on The Patient Transfer & Referral Record, dated March18, 2009, indicated the reason for Patient A's transfer was "[Respiratory] Arrest" (stopped breathing). Under Report of Hospital Nurse, documentation indicated, "...CHOKED DURING NOON MEAL, FOOD REMOVED...STARTED SPEAKING THEN COLLAPSED SUDDENLY." The (Paramedic) Medical Response team arrived at the facility on March 18, 2009, at 12:26 p.m. Documentation on the PREHOSPITAL PATIENT CARE REPORT indicated the [name of city] Fire Department was the "First Responder" to the facility. Patient A was nonresponsive with, "CPR in progress." Patient A was pulseless. At 12:32 p.m., the paramedic inserted an endotracheal tube (placement of a tube into the throat to allow air flow). Documentation indicated Patient A remained unresponsive. The paramedic administered Epinephrine (to stimulate heart activity) at 12:37 p.m. Documentation indicated Patient A's pulse was irregular at 12:42 p.m. Patient A departed the facility at 12:49 p.m., remained unresponsive and required cardiac compressions enroute to the acute care hospital. Documentation on the acute care hospital's EMERGENCY DEPARTMENT FLOWSHEET, indicated, "Aspirated (the sucking in of food particles or fluids into the lungs) food then went into full arrest." Patient A's care plan for Nutritional Risk, dated, March 9, 2009, included, "Chewing Problem, Needs Mechanically Altered Diet, Therapeutic Diet - [mechanical] soft [no added salt]." The facility's policy titled, Ground (Mechanical Soft) Diet, described: "The ground or mechanical soft diet consists of foods which are soft in texture or modified to minimize the amount of chewing necessary for ingestion of food. This diet is based on the regular diet and includes foods which are ground according to the individual needs." The facility's Daily Menu Spreadsheet for March 18, 2009, identified the Ground menu as a ground meat/entr‚e, mashed potatoes, soft cooked vegetable, dinner roll, diced canned fruit, gravy, margarine pat, whole milk. The "Regular" menu included roast turkey, mashed potatoes, zucchini, dinner roll, fruit cobbler, gravy, margarine pat and whole milk. RNA 1 (Restorative Nursing Aide) was interviewed on April 24, 2009, at 3:33 p.m., and stated, "[Patient A] was at a table by himself. [CNA 1] told me to, 'come over here'. I went over and looked at him and thought he was silent aspirating. [Patient A] was saying 'huh' when we called his name. I started Heimlich. Meat was coming out - turkey, pieces of turkey and bread. I kept doing Heimlich and told [CNA 1] to watch for food. I had him stand up...kept doing Heimlich until [LVN 1] came and took over. [Other] staff came, we paged code blue. [We] took [Patient A] to his room. The meal was turkey with gravy, dinner roll, mixed vegetables. The turkey was like canned - sliced or chunks. It was not ground turkey." Dietary Supervisor 1 was interviewed on April 23, 2009, at 11:46 a.m., and stated, "[Patient A] was transferred to [a different room]. The patient who was in that room was on a regular diet. I wrote Regular on the diet card for [Patient A]. [Patient A] received a regular diet of roast turkey that day. [Patient A] was known to stuff his mouth. [Patient A] should have had a mechanical soft diet which has a ground texture." On March 18, 2009, at 12:20 p.m., Patient A choked and aspirated while eating a regular diet. Emergency measures were applied: cardiopulmonary resuscitation and intubation (placement of a tube into the throat to allow air flow). Patient A was transferred to an acute care facility and placed on a ventilator (an automatic breathing machine). The above violations either jointly, separately, or in any combination, presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 250000021 |
RIVERSIDE BEHAVIORAL HEALTHCARE CENTER |
250011724 |
B |
23-Sep-15 |
RKQN11 |
5719 |
483.13(c) (2)Reporting alleged violations and the results of investigations to the State survey agency...as soon as possible, but ought not exceed 24 hours after discovery of the incident.The facility failure to ensure the charge nurse immediately reported an allegation of suspected sexual abuse by Certified Nurses Assistant (CNA 1) to Patient 1 to the Administrator and/or the Director of Nursing. The facility failed to report the allegation of sexual abuse by Certified Nurse Assistant 1 to Patient 1 within 24 hours to the ombudsman, local law enforcement, resident's responsible party,or to the California Department of Public Health (CDPH).The facility is licensed as a Skilled Nursing Facility with a Special Treatment Program for psychiatric residents. On September 23, 2014 at 2:45 p.m., an unannounced visit was made to the facility to investigate a complaint of alleged sexual abuse of one patient, Patient 2 by Certified Nurse Assistant 1. Upon entrance to the facility, an interview was conducted with the Director of Nursing (DON). The DON stated that only one of two incidents of alleged sexual abuse by Certified Nurse Assistant 1 to two different patients had been reported to the California Department of Public Health. The incident involving Patient 2 was reported to the California Department of Public Health however the incident involving Patient 1 had not been reported to the California Department of Public Health. During this interview, the DON indicated that on September 13, 2014, Patient 3 reported to the Charge Licensed Vocational Nurse 1 (Charge LVN 1) that Patient 1 had confided to Patient 3 and told him that while he was naked in the shower, Certified Nurse Assistant 1 peeked his head around the corner of the shower and asked him uncomfortable questions such as, "Are you gay?" and "Do you like guys? " Patient 1 committed suicide on September 10, 2014, by hanging himself from a fire sprinkler with a bed sheet in his bathroom.A concurrent review of the facility document titled,"Interdisciplinary Team Notes," dated September 13, 2014 at 1745, signed by Charge LVN 1, indicated, " When (Patient 1's name) was taking a shower, this staff was asking (Patient 1's name) uncomfortable questions such as are you gay, heterosexual ?, do you like guys? According to (Patient 3's name), when he was talking to (CNA 2's name), the description of this staff was tall, big, black and talks a lot. When the name (CNA 1's name) was raised, (Patient 3's name) agreed to the person."On September 24, 2014 at 2:50 p.m., an interview was conducted with Patient 3. Patient 3 stated, "That prior to the suicide of my friend, he had confided in me that (CNA 1's name) had peeked his head around the corner of the shower and asked (Patient 1's name) questions about being gay. (Patient 1's name) told (CNA 1's name) that he was straight. (Patient 1's name) said he didn't like it and I could tell by the way he was talking about it that he was uncomfortable with it. He just shrugged it off and didn't tell anyone. I didn't tell anyone because it really didn't matter to me. I told the staff about what (Patient 1's name) told me to relieve my conscience after he (Patient 1) hung himself." Patient 3 could not recall a time frame for this conversation. A review of facility time sheets indicated that on September 13, 2014, after Charge LVN 1 was made aware of the alleged sexual abuse by CNA 1 to Patient 1, CNA 1 continued to work in direct contact with residents. CNA 1 worked the remainder of his shift on September 13, 2014, his regular schedule shift on September 14, 2014, his regular schedule shift plus overtime on September 15, 2014, and his regular schedule shift on September 16, 2014.On September 24, 2014, at 5:00 p.m., during an interview, the DON indicated CNA 1 continued working for three days after the alleged sexual abuse was reported to Charge LNV 1 and CNA 1 was not suspended until the end of his shift on the fourth day, September 16, 2014. The DON also stated, "I was not made aware of the incident until Monday, September 15, 2014. The 13th was a weekend. We were a bit consumed with the current suicide of our patient, (Patient 1's name). That was the time the deceased patient's family was coming in. I have not yet reported it" The DON was not able to produce any documentation supporting the initial incident of alleged sexual abuse by CNA 1 to Patient 1 had been reported to nursing administration, the administrator (ADM), California Department of Public Health, the resident's responsible party, or any other agency.On April 20, 2015 a review of the facility's undated policy and procedure on abuse reporting was reviewed. The facility's abuse policy and procedure indicated:B. If the suspected perpetrator is an employee:2. Suspend employee during the investigation. 2. If the reportable event results in bodily injury or sexual abuse, the staff member shall report the suspicion immediately to local law enforcement and within two hours a written report to ...licensing agency... C. First responder or first staff member informed will be responsible for informing immediate supervisor and initiating incident report. D. the ADM ... and DON must be notified immediately after the incident is reported." The facility failed to ensure that an allegation of sexual abuse was reported. The facility failed to report the allegation of sexual abuse by CNA 1 to Patient 1 to the California Department of Public Health within 24 hours.These failures had the potential to subject all facility residents to sexual harm by CNA 1.The above violations either jointly, separately or in any combination had a direct or immediate relation to patient health, safety, or security. |
| 250000021 |
RIVERSIDE BEHAVIORAL HEALTHCARE CENTER |
250011725 |
B |
23-Sep-15 |
MIU111 |
4883 |
483.13(c) (2)Reporting alleged violations and the results of investigations to the State survey agency...as soon as possible, but ought not exceed 24 hours after discovery of the incident.The facility failed to ensure the charge nurse immediately reported an allegation of abuse between Patient 1 and Patient 2 to the Administrator and/or the Director of Nursing. The facility failed to report the allegation of Patient to Patient abuse within 24 hours to the Ombudsman, local law enforcement or to the California Department of Public Health (CDPH). The facility is licensed as a Skilled Nursing Facility with a Special Treatment Program for psychiatric Patients. On April 22, 2015, at 11:20 a.m., an unannounced visit was made to the facility to investigate a complaint of alleged physical abuse between Patient 1 and Patient 2.Upon entrance to the facility, an interview was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The DON stated, "Rooms were moved. The night Certified Nursing Assistant reported seeing Patient 1 in bed prior to the incident and didn't see him get out of bed. Certified Nursing Assistant 1 didn't see either patient get out of bed during the entire time frame of the alleged incident. After the incident Certified Nursing Assistant 1 didn't see any red marks on patient 1's face. It came down to one patient's word against another."On April 22, 2015, a review of the facility's Behavioral Incident Report dated April 13, 2015, indicated at approximately 2222 (10:22 p.m.) on April 13, 2015, Patient 1 came out of his room and reported he was hit one time on his left jaw by his roommate, Patient 2. The Charge Nurse, Licensed Vocational Nurse 1, was made aware of the alleged abuse and signed the incident report as having updated or initiated the care plans. A concurrent review of the facility Interview Record dated April 14, 2015, indicated Certified Nursing Assistant 1 was the first staff to make contact with Patient 1 after the alleged abuse. Certified Nursing Assistant 1 indicated, "I just checked that row of rooms and Patient 2 was in his bed the entire time. I was walking away when I heard yelling and went back to the room to see Patient 2 still in bed and Resident 1 coming from behind his curtain stating my roommate struck me. But it couldn't have happened." This interview was conducted by Licensed Vocational Nurse 1.On June 25, 2015, at 2:40 p.m., a second interview was conducted with DON and ADON to clarify why the alleged incident was not reported within 24 hours of discovery. DON stated the incident of alleged abuse between Patient 1 and Patient 2 was first reported by Patient 1 to Certified Nursing Assistant 1 on April 13, 2015, at approximately 2222 (10:22 p.m.). It was then reported to the charge nurse for that night and that nurses station who was Licensed Vocational Nurse 1. DON then stated, "It wasn't immediately reported up the chain because no one thought it was an incident. Two days later, (April 15, 2015), at stand-up the alleged abuse event came out and was discovered by myself and ADON. I was off the next day so it was the following day, we spoke to Licensed Vocational Nurse 1 and she stated no one got hit and it didn't happen. The incident report didn't get done because nothing happened. Staff saw both parties in bed all night. The next day, (April 15, 2015), in stand-up we were reading the report and thought we should investigate further. The ADON did another investigation just to make sure nothing happened. Based on what ADON found it was decided the alleged abuse did need to be reported. That's when we notified CDPH, the Ombudsman and law enforcement." On April 22, 2015, a review of the facility's undated Abuse Policy and Procedure indicated, "Whenever client to client abuse is witnessed or reported to have occurred staff will implement the following steps to assure client safety:...6. Complete SOC341 form, call in report and fax form to LTC Ombudsman Law enforcement/CDPH...13. Notify Administrator, Director of Nursing and Program Director of incident." The facility failed to ensure the licensed charge nurse immediately reported to the Administrator and the Director of Nursing one reported incident of alleged abuse between Patient 1 and Patient 2. The facility failed to immediately report the allegation of patient to patient abuse to the Ombudsman and local law enforcement, reporting approximately one and a half days later.The facility failed to report the allegation of patient to patient abuse to the California Department of Public Health within 24 hours, reporting approximately one and a half days later.These failures had the potential to subject all facility patients to physical harm.The above violations either jointly, separately or in any combination had a direct or immediate relation to patient health, safety, or security. |
| 250000073 |
Riverside PostAcute Care |
250011919 |
B |
07-Jan-16 |
YSTT11 |
6679 |
483.25 (h) FREE FROM ACCIDENT HAZARDS/ SUPERVISION/ DEVICES The facility failed to ensure residents were free from accident hazards from wildlife on facility premises. The facility failed to ensure residents were protected from injuries caused by wildlife. The facility allowed residents to feed wild raccoons for over a year, resulting in injuries to Patient A, who was bitten and scratched by wild raccoons on February 8 and 10, 2015, while sitting outside on facility grounds. Patient A required an emergency room visit, wound treatment to both arms, immunizations, and rabies vaccinations. The facility failed to ensure wild raccoons were effectively removed from the facility premises, until February 10, 2015, after Resident A was scratched a second time by a wild raccoon. Wild raccoons were observed on facility grounds for over a year prior to the first incident of Resident A being bitten by a wild raccoon on February 8, 2014. On February 17, 2015, at 1:50 p.m., an unannounced visit was made to the facility to investigate a complaint allegation that one resident, Resident A, was attacked by a raccoon. An interview was conducted with Resident A on February 17, 2015, at 1:55 p.m. During the interview, a dry, scabbed area approximately 0.5x0.5 centimeters, was observed on the residents left upper arm area. Resident A stated on February 8, 2015, he was sitting outside of the facility when he observed a raccoon climbing down a nearby tree. He stated the raccoon jumped on him and bit the lower part of his left upper arm. He stated the wound bled "a lot" and he was taken to the hospital for treatment including rabies shots. Resident A stated he was sitting at the back of the building two days later, on February 10, 2015, when another raccoon jumped on him. As he attempted to push the raccoon away, he was scratched by the raccoon's claws on the lower part of his left upper arm. During a second interview conducted with Resident A on February 27, 2015, at 11:30 a.m., he stated the first dose of the Rabies vaccine was very painful and his arm got sore. After the second dose he experienced abdominal pain and nausea. The third dose was painful and left him with numbness on his left arm, In addition, after the third dose he vomited four times.On February 17, 2015, a record review was conducted for Resident A. The resident was admitted to the facility on September 26, 2014. A History and Physical dated September 29, 2014, indicated the resident was had the capacity to make his own decisions.During an interview conducted with the facility administrator on February 17, 2015, at 2:10 p.m., he stated there were at least three raccoons on the facility grounds. He stated a company was located who would come out and trap the raccoons, but temporarily the facility ordered a trap, which was due to be delivered the date of the interview (nine days after Resident A's first injury by the raccoons). During an interview conducted with the assistant director of nursing on February 17, 2015, at 2:35 p.m., she stated she first saw the raccoons on the facility grounds around the end of January 2015, two or three weeks before Resident A was injured by the raccoons.During an interview conducted with Resident A on February 26, 2015, at 3:15 p.m., he stated he observed Resident B feeding the raccoons every night by hand before he was discharged from the facility three weeks before the interview. Resident A stated he observed the raccoon's nest in the top of the tree with four babies and a mother in the nest. Resident A stated a week after he was bitten by the raccoon, a sign was posted on the back door which read, "Please do not feed the Raccoons." On March 26, 2015, a record review was conducted for Resident B. The resident was admitted to the facility on November 15, 2014, and discharged on February 6, 2015. Interdisciplinary Progress Notes included the following: Dated January 12, 2015, "On January 11, 2015 (Patient B's name) was attempting to hand feed raccoon outside and fell on his bottom. " Dated January 14, 2015, "On January 13, 2015, at 1950 (7:50 p.m.), (Patient B's name) had a witnessed fall outside on smoke area. Res (another resident) witnessed resident (Resident B's name) was trying to feed raccoons and fell on his side." A Nurses Note dated January 13, 2015, at 10:25 p.m., indicated, "Animal Control contacted but it was after hours, will be endorsed in am." During an interview conducted with Licensed Vocational Nurse 1 (LVN 1) on February 26, 2015, at 3:40 p.m., she stated she had worked for the facility for a year. During that time, she saw the raccoons daily, and saw Resident B feeding the raccoons every day before he was discharged. On February 26, 2015, at 3:55 p.m., Family 1 was interviewed. He stated he had seen the raccoons for more than a year and has watched a resident feeding them. He stated when he saw the raccoons outside he always went back inside the building because he felt the raccoons were dangerous. Family 1 stated he reported the raccoons to the maintenance department and was told they would call Animal Control, but for one year and nine months nothing was done. Family 1 stated he stopped reporting the raccoons because no one was listening to his concerns.An interview was conducted with the facility contracted Pest Control Services technician on March 5, 2015, around 7 p.m. He stated he witnessed a woman feeding the raccoons by hand on February 19, 2015, around 7 p.m. He stated he reported the incident to nursing immediately. During an interview conducted with the Activity Aide on February 27, 2015, at 10:15 a.m., she stated she has seen the raccoons, usually at night since the end of 2014. She stated a resident told her that he bought a box of bread to feed the raccoons.During an interview conducted with Resident C on February 27, 2015, at 10:30 a.m., she stated she has seen the raccoons hanging around the building for the last year. She reported watching another patient throwing food into the bushes for the raccoons, including her own food. She stated she observed one female resident feeding the raccoons every day for a year. Resident C stated she told the Administrator and Social Services.During a recertification survey conducted from December 12-30, 2014, survey team members reported there were no warning signs posted in any location at the facility to warn residents or the public against feeding the raccoons.The facility failed to take action against a known infestation of vermin (raccoons) at the facility. As a result, Resident A was scratched and bitten by raccoons.This violation had a direct relationship to the health, safety, or security of patients. |
| 250000021 |
RIVERSIDE BEHAVIORAL HEALTHCARE CENTER |
250012712 |
B |
10-Nov-16 |
YV3M11 |
5554 |
Health and Safety Code 1424 (e) Except as provided in paragraph (4) of subdivision (a) of Section 1424.5, class "B" violations are violations that the state department determines have a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents, other than class "AA" or "A" violations. Unless otherwise determined by the state department to be a class "A" violation pursuant to this chapter and rules and regulations adopted pursuant thereto, any violation of a patient's rights as set forth in Sections 72527 and 73523 of Title 22 of the California Code of Regulations, that is determined by the state department to cause or under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to a patient is a class "B" violation. A class "B" citation is subject to a civil penalty in an amount not less than one hundred dollars ($100) and not exceeding one thousand dollars ($1,000) for each and every citation. ?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. Title 42 of the Federal Code of Regulations ? 483.70 Physical Environment The facility must be designed, constructed, equipped and maintained to protect the health and safety of residents, personnel and the public. The facility failed to prevent residents with a history of depression and/or suicide attempts from attempting suicide by hanging themselves from the fire suppression sprinkler heads located within the facility restrooms. On September 23, 2014, an investigation was conducted into an entity reported incident regarding a suicide that occurred on September 10, 2014.The facility reported that, on September 10, 2014, a resident (Resident 2), a 21 year old male, used a bed sheet tied to the fire suppression sprinkler in the restroom to hang himself. Resident 2 expired on September 10, 2014. On January 5, 2015, an unannounced visit was made to the facility to investigate a second entity reported incident that Resident 1, a 19 year old female, was found by the facility on January 3, 2015, at 8 pm, hanging by a bed sheet tied to the fire suppression sprinkler in the facility. On January 5, 2015, at 3 p.m., an interview was conducted with the Administrator (ADM). The ADM stated, after Resident 2's September 10, 2014 suicide, the ADM had discussed the possibility of installing non-ligature fire suppression (sprinkler heads that were flush with the ceiling, making it impossible to tie a sheet on to them) with the corporate office. The ADM stated that no decision had been made by the licensee about the installation of the non-ligature fire suppression sprinkler heads at the time of Resident 1's subsequent suicide on January 5, 2015. In addition, the ADM stated there was no increase in monitoring of the resident population implemented from September 10, 2014, through January 3, 2015. On January 5, 2015, a record review was conducted for Resident 1, who was admitted to the facility with diagnoses including Bipolar Disorder (recurrent moods of excessive excitement and depression) and a history of suicide attempts. The Certification for Special Treatment, dated August 26, 2014, indicated Resident 1 had previous attempts of suicide including an overdose of pain medication and lithium (medication to treat bipolar disorder). The resident maintained a suicide journal. A review of a Progress Note for Resident 1, dated December 14, 2014, revealed the description of Resident 1 as glum and unhappy with depressed thought content and a negative attitude. The resident's quarterly care plan dated November 7, 2014, also reviewed, listed suicidal behaviors as a potential problem and indicated Resident 1 made two suicidal statements in the past quarter. Resident 1 had been on every 15 minute behavior watch for attempting to leave the facility without permission. This behavior watch was discontinued on December 31, 2014, three days before the resident committed suicide. On January 5, 2015, at 1:45 p.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 1 knew Resident 2, who previously committed suicide in the same manner on September 10, 2014. The DON stated Resident 1 was taken off every 15 minute behavior watch three days before her suicide. An interview was conducted with the ADM on January 16, 2015, at 12:35 pm. The ADM stated there was no progress toward installing an alternate sprinkler head. The ADM stated he needed corporate approval for the changing of the fire sprinkler suppression heads. The ADM stated he could not make an $80,000 decision on his own. The facility failed to provide the necessary care and services and failed to ensure a safe physical environment for Resident 1, a resident with a recent history of suicide attempts, when the facility failed to adequately monitor Resident 1 to prevent suicide attempts by use of fire suppression sprinklers located in the facility restrooms. As a result, on January 3, 2015, Resident 1 used a sheet tied around her neck and tied to the fire suppression sprinkler head in the restroom, to commit suicide. The above violations either jointly, separately, or in any combination, presented either an imminent danger that death or serious physical harm would result or substantial probability that death or serious physical harm would result. |
| 250000081 |
RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC |
250012952 |
B |
15-Feb-17 |
2Z6C11 |
12491 |
483.12(a)(7) Orientation for Transfer or Discharge
A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility.
On May 26, 2016, a complaint was received from a licensed clinical social worker (LCSW 1) at an acute care hospital. LCSW 1 reported that Resident 10 had been brought to the hospital's emergency room by the (name of local city omitted) Police Department who had found Resident 10 wandering the streets. The resident was unable to provide adequate information to the hospital staff about where she lived upon arrival at the emergency room.
During the complaint investigation, it was determined that the facility failed to ensure one resident (Resident 10) was provided a safe and orderly transfer from the facility when she had eloped (ran away) from a room and board to where she had been discharged without any preparation or orientation to the room and board.
On May 26, 2016, at 2 p.m., a phone interview was conducted with LCSW 1 from the acute care hospital. LCSW 1 stated the hospital's staff had finally located the skilled nursing facility (SNF) where Resident 10 was living prior to the unsafe discharge to a room and board facility. LCSW 1 stated she had made several attempts to contact the facility without success. In the LCSW 1's written complaint to the California Department of Public Health she wanted to know how the facility was able to determine, "Why this Pt (patient- Resident 10) was discharged to a room and board knowing that she (Resident 10) needed a higher level of care?" The LCSW repeated the question during the conversation. LCSW 1 stated that the resident had been at the acute hospital for three days, and when she was offered food, the resident refused it and told the hospital staff that she had no money to pay for it. Resident 10 would not accept a hospital bed for the same reason.
On May 26, 2016, at 3:15 p.m., an unannounced visit was made to the facility to investigate the complaint from LCSW 1 related to a possible inappropriate discharge.
On May 26, 2016, Resident 10's facility medical record was reviewed. The facility record indicated that the resident had an original admission date of XXXXXXX 2015, with a readmission date of XXXXXXX 2016. Resident 10's diagnoses included schizoaffective disorder (mental health condition in which a person experiences a combination of hallucinations and/or delusions, mood disorder symptoms such as depression or mania) and dementia (memory problems that interfere with daily functioning) with behavioral disturbances.
Resident 10's Minimum Data Set (MDS- an assessment tool), dated March 14, 2016, was reviewed and indicated the resident's BIMS (Brief Interview for Mental Status- a test used to detect cognitive impairment) score was seven. A score of 0-7 reflects severe cognitive impairment per the 3.0 Resident Assessment Instrument (RAI). The MDS further indicated Resident 10 needed supervision and some oversight to perform her activities of daily living such as walking in and around the facility, dressing, eating and personal hygiene.
During continued review of Resident 10's facility record, three physician telephone orders were located regarding Resident 10's first admission's discharge. On December 14, 2015, a hand written order indicated, "Clear to D/C (discharge) when Arrangements made for Discharge." There was no location indicated in the order where the resident would go upon discharge. The second hand written order on December 14, 2015, read, "Home Health (with) (Name of agency and phone number)." The order failed to name any facility or place where the resident would go upon discharge.
A nurse's note dated December 14, 2015, indicated Resident 10's physician had been in to see the resident, assessed her, and gave an order to discharge the resident. No additional documents with discharge location could be located in the medical record provided by facility staff that indicated Resident 10 had been discharged on or around the XXXXXXX 14th date.
A hand written order, dated February 2, 2016, indicated, "D/C to (name of a sister facility omitted). The order had not been signed by Resident 10's physician. No documents or discharge forms were located in the resident's facility medical record to indicate that the February 2, 2016, discharge order to the new facility had been carried out.
Further review of Resident 10's facility record on May 26, 2016, located copies of records sent to the facility from an acute care hospital in northern California. These records indicated that Resident 10 had been admitted to the northern hospital (approximately 450 miles from SNF in Riverside County) on February 23, 2016, after she was found "wandering around." The acute hospital's LCSW (LCSW 2) documented, "Patient (Resident 10) states she is from LA (Los Angeles) and was put on a bus to San Francisco, but cannot report why she was sent there. She states that she was on a bus back to LA, but that she got out at a stop to use the bathroom and the bus had left when she returned." LCSW 2 further wrote that she, "Keeps repeating that she wants to go back home and that her family will come and get her."
The acute hospital in northern California located a son who stated that the resident had a history of schizophrenia and had refused treatment in the past. He said he no longer wanted to be involved in Resident 10's life. The resident was discharged back to the skilled nursing facility (SNF) from the acute hospital in northern California on XXXXXXX 2016, eight days after admission to the acute hospital. In the acute hospital's Social Worker note, LCSW 2 wrote that he had spoken to the SNF's Case Manager who told him the SNF "will take pt (patient) back." There was no indication in the acute records of how the hospital staff knew Resident 10 had been a resident in the current SNF. The acute hospital's Case Manager wrote, "Requires custodial SNF secured unit." Transportation back to the SNF was arranged by the acute hospital in northern California.
Further review of the facility record indicated Resident 10 was readmitted to the Riverside County SNF on XXXXXXX, 2016. A care plan written on that date indicated that the resident was at risk for AWOL (absent without leave or elopement). Interventions for the concern were "Q (every) 15 (minutes) monitoring," and "Encourage pt to verbalize needs & (and) concerns."
The facility form, "History and Physical," completed by Resident 10's physician and dated "3/17" (March 17, 2016), indicated a diagnosis of dementia and that Resident 10 did NOT have the capacity to understand or make decisions. There was no record of a surrogate decision maker listed on the history and physical form. The line was left blank.
On April 20, 2016, the physician wrote that Resident 10 was confused and wandering about in the facility hallway. The physician's assessment was dementia.
On May 3, 2016, the physician indicated that the resident was delusional.
On May 10, 2016, the physician wrote that Resident 10 had dementia and needed supportive care.
On May 18, 2016, the psychiatrist who saw the resident wrote that Resident 10 had dementia. The psychiatrist's plan was for supportive care.
Continued review of Resident 10's facility record on May 26, 2016, located a hand written physician order signed by a nurse on May 20, 2016, that indicated, "D/C to (Name, address, and phone number of facility)," a room and board. A second hand written order signed by a nurse and dated May 21, 2016, indicated, "Resident may D/C to (same name, address, and phone for facility)."
The facility form titled, "Social Services Discharge Planning," dated and signed by the Social Services Designee (SSD) on May 20, 2016, indicated Resident 10, "Has a (sic) order to discharge to (name of room and board) in (name of city omitted) to a lower level of care. No orders for Home Health or DME (durable medical equipment) at this time - none needed. Resident will discharge with all her belongings and medications. Resident is self-responsible...Resident needs to schedule a follow up appointment with her primary MD (medical doctor) in 1 or 2 weeks from discharge date." The form further indicated that Resident 10 would be transported by the owner's (room and board's owner) private van.
A room and board is defined in Webster's New World College Dictionary as sleeping accommodations and meals.
The facility form, "Notice of Proposed Transfer/Discharge," indicated the notification date given to Resident 10 was May 19, 2016, with an effective date of May 20, 2016. The reason for discharge indicated it was appropriate because, "Your (Resident 10) health has improved sufficiently so that you no longer require services provided by this facility..." The form was signed and dated by the facility's SSD on May 21, 2016. The resident, who was named as self-responsible, did not sign the form. A person from the accepting facility (room and board) signed it. She did not indicate any relationship to Resident 10 on the space provided.
On May 26, 2016, at 3:30 p.m., a concurrent interview was conducted with two facility admission coordinators (AC 1 and AC 2).
AC 1 was asked if she thought a room and board was proper placement for Resident 10. AC 1 stated that the facility's SSD checked out the facilities (room and board facilities). The SSD thought it was appropriate placement for Resident 10.
AC 2 was asked if the owner of the room and board had met Resident 10 before the resident was accepted to live in her room and board. She said the owner told them she could take the resident and thought the owner was told about Resident 10's behaviors. AC 2 could not say what Resident 10's behaviors were.
Both ACs were asked if they knew where Resident 10 was at the present time. AC 1 said she was told earlier that Resident 10 had run away from the room and board facility.
An interview was conducted with the Director of Nursing (DON) on May 26, 2016, at 4 p.m. He agreed that Resident 10's discharge to a room and board was an inappropriate discharge. He stated that the SSD made the arrangements for placement of residents who were not discharged to family.
On June 6, 2016, at 10:50 a.m., an interview was conducted with the SSD. She stated that the resident looked "so sad all the time and wanted to leave." She said that she thought the resident would be happier at the room and board, and the room and board owner said she could take care of the Resident 10. The SSD stated she was not aware that Resident 10 had not been taken to the room and board listed on the discharge form, but she knew that the owner had a second home and was trying to fill it (populate the home). The SSD said that Resident 10 was her first admission to the new home. When asked if she thought a room and board was appropriate placement for Resident 10, the SSD did not answer.
The facility's undated policy and procedure, titled "Policy and Procedure on Discharge Planning," was reviewed on June 7, 2016. It indicated, "It is the policy of this facility to provide ongoing evaluation and discharge planning for all appropriate residents while in the facility...3. Upon admission, Social Services shall determine potential for resident to be discharge (sic) to a lower level of care or home care...9. Social Services shall also be responsible for coordination with the resident and/or family surrogate decision maker and appropriate disciplines regarding any home equipment, environmental set-up, supervision...that are needed once the resident has been discharged..."
Using the reasonable person concept, the facility caused psychological harm to Resident 10 by removing her from surroundings that were known to her. This move caused her to run away from the board and care home to the city streets where Resident 10 could have sustained serious injury or harm inflicted on her by others until she was taken to a safe place, the acute care hospital, where her needs were met.
Therefore, it was determined that the facility failed to ensure Resident 10 was provided a safe and orderly transfer from the facility when the resident was found by police officers wandering the streets and was taken to an emergency room of the acute hospital.
The violation of the above regulation had a direct relationship to the health, safety, or security of the resident. |
| 250000081 |
RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC |
250012963 |
A |
2-Mar-17 |
UKM711 |
7675 |
F323, 483.25 (d) (2)
The facility must ensure that-
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
On October 4, 2016, an unannounced visit was conducted to investigate an entity reported incident. It was determined that the facility failed to ensure Resident A received adequate supervision to prevent accidents. This failure resulted in Resident A having a fall, and suffered a left shin and left ankle fracture (break in the continuity of the bone) that required three surgical treatments to repair the left shin and left ankle fracture.
On October 4, 2016, a review of Resident A's medical record was conducted. Resident A was a 49 years old female admitted to the facility on XXXXXXX2016, with diagnoses that included bipolar disorder (mental disorder) and anxiety.
The MDS (Minimum Data Set- an assessment tool), dated August 18, 2016, indicated Resident A had moderate cognitive impairment (inability to think and/or decide with reasoning) and disorganized thinking. The MDS also indicated Resident A needed supervision with no physical help from staff with her bed mobility, transfer, walking, locomotion on and off unit, dressing, toilet use and personal hygiene.
The care plan, dated May 5, 2016, identified Resident A was at risk for elopement (act or instance of running away) and had the behavior of running outside during the night shift stating "I'm getting out of here." The facility's intervention for the elopement problem included, "One on One (one facility staff to monitor and/or observe one resident at all times)."
On June 17, 2016, at 5:07 p.m., the licensed nurse progress notes indicated Resident A was seen by another resident climbing out of the window in Room 9. The notes further indicated Resident A was found "laying" in the bushes in front of the building. After the incident on June 17, 2016, a care plan dated June 18, 2016, was developed. The care plan indicated Resident A had attempted to leave the facility and the facility's intervention was to continue monitoring Resident A on "strict 1:1 (one on one)" with CNA (Certified Nursing Assistant).
On September 27, 2016, at 9:28 a.m., the licensed nurse progress notes indicated Resident A was found outside the fence by the kitchen at around 12 midnight. The notes further indicated Resident A stated she hurt her foot and Resident A had swelling and pain on her left ankle and foot.
XXXXXXX27, 2016, at 1:40 p.m., Resident A was transferred to the general acute care hospital emergency room for further evaluation due to an injury on her left ankle with possible fracture.
On October 4, 2016, at 8:42 a.m., an observation of the outside fence was conducted with the facility Acting Director of Nursing (ADON). The ADON stated on September 27, 2016, sometime during the night shift, Resident A climbed over the fence which was approximately nine feet above the ground level, and fell to the ground on the other side of the fence. The ADON further stated, Resident A was supposed to be monitored 1:1 due to previous attempts of elopement in the facility. The ADON stated CNA 1 was supposed to provide 1:1 monitoring on Resident A; however, CNA 1 was actually assigned to monitor both Resident A and her roommate before the incident happened. The ADON acknowledged facility did not follow Resident A's care plan for one on one monitoring.
On October 10, 2016, at 3:54 p.m., an interview was conducted with CNA 1. CNA 1 stated on the night shift of September 27, 2016, she was assigned to provide 1:1 monitoring for both Resident A and her roommate. CNA 1 stated both Resident A and her roommate had behavioral problems and had to be monitored 1:1 all the time. CNA 1 stated she had to "clean" Resident A's roommate and was not able to stop Resident A when she left the room. CNA 1 stated by the time she had the chance to look for Resident A, the resident had already climbed over the fence and fell to the ground. CNA 1 stated she did not provide 1:1 monitoring on Resident A because she had to watch the roommate at the same time.
On November 23, 2016, at 10:15 a.m., the facility Administrator was interviewed. The Administrator stated 1:1 monitoring on a resident would mean one CNA will be assigned to monitor only one resident. The Administrator stated the CNA assigned to provide 1:1 should be with the resident at all times.
The facility's undated policy and procedure titled, "One-On-One Observation Policy and Procedure," was reviewed. The policy indicated, " ...When a resident's condition changes ...IE: behavioral natures ...elopements...a One-On-One Observation will be implemented..."
On XXXXXXX, 2016, Resident A was admitted to the acute care hospital with diagnoses that included comminuted fracture (break or splinter of the bone on more than two fragments) on the left tibia (shin bone), left ankle malleolus (bony prominence at the sides of the ankle) and diffused (spread) left ankle tissue swelling.
During Resident A's acute care hospital stay, she underwent three major surgeries:
- On September 29, 2016, an external fixator (the method of applying pins and screws into the bone of both sides of the fracture to allow to heal) was applied on the left ankle. A posterior splint (strip of rigid material used to support and immobilize a broken bone) was applied to the left leg as well. According to the operative report it was determined Resident A was not ready for an open reduction and internal fixation (ORIF- surgical procedure to fix a severe bone fracture) due to significant blistering and swelling on the left ankle.
-On October 6, 2016, the external fixator on the left ankle was removed and an ORIF was conducted on the left distal tibia, and left ankle malleolus. A coaptation/stirrup splint (type of splint) with posterior splint was applied on the left leg as well. According to the operative report, the surgery was a medical necessity for the resident's continued proper orthopedic care (treatment involving muscles and bones); and
- On October 17, 2016, a wound debridement (removal of damaged tissue or foreign object from a wound) was done on the left ankle surgical wound, then a left distal fibula (smaller of the two bones between the knee and ankle) ORIF was conducted. After the procedure a posterior splint with coaptation/stirrup splint was again applied.
On October 16, 2016, the physical therapy evaluation notes indicated Resident A had impaired mobility and cannot bear weight on her left lower extremity. Resident A needed total assistance with her mobility such as walking, transferring self from bed to chair and climbing the stairs. Resident A had to wear a CAM (controlled ankle motion) boot on her left lower extremity during ambulation.
As of January 9, 2017, Resident A was still in the general acute care hospital medical-surgical ward and is awaiting for placement to a nursing facility. Resident A continues on physical therapy treatment to her left lower extremity. The physical therapy progress notes, dated January 6, 2017, indicated Resident A partially bears weight on her left lower extremity. The progress notes further indicated Resident A continues to wear the CAM boot on her left lower extremity and had to use the front wheel walker in order for her to be able to ambulate safely and independently.
Resident A suffered pain and physical harm, underwent three major surgeries and loss of function due to the facility's failure to provide adequate supervision.
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. |
| 250000081 |
RIVERSIDE HEIGHTS HEALTHCARE CENTER, LLC |
250013005 |
A |
9-Mar-17 |
2Z6C11 |
22073 |
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
483.12(a) The facility must-
(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
On August 22, 2016, at 10:40 a.m., an unannounced visit was made to the facility for the investigation of two complaints.
During the investigation it was determined that the facility failed to ensure one resident (Resident 9) in a universe of 69 residents received treatment and care in accordance with professional standards of practice after two falls resulting in a severe head injury. Resident 9 required transportation to an acute care hospital's emergency department by paramedic ambulance where he underwent emergent brain surgery and ultimately died nine days later. The facility failure to accurately assess Resident 9's head injuries resulted in the resident not receiving essential medical attention for life-saving interventions.
A review of Resident 9's facility medical record was conducted. Resident 9, a 63 year old male, was admitted to the facility on XXXXXXX2016. The resident's diagnoses included Parkinson's disease (disorder of the central nervous system that affects movement), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), type 2 diabetes (condition that affects the way the body processes blood sugar), atrial fibrillation (A-fib- irregular, often rapid heart rate that causes poor blood flow), dementia (memory problems that interfere with daily functioning) anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear), and schizophrenia (brain disorder which causes one to interpret reality abnormally).
Resident 9's facility document titled, "History and Physical," (H&P) dated August 1, 2016, failed to indicate whether the resident had capacity to understand and make decisions. This section of the H&P was left blank.
Review of Resident 9's facility document titled, "Physician Orders for Life Sustaining Treatment," (POLST) dated August 1, 2016, indicated, "Attempt Resuscitation/CPR," (lifesaving technique used in emergencies when breathing or heartbeat have stopped). The POLST further indicated that medical interventions were to include, "Full Treatment- primary goal of prolonging life by all medically effective means."
A review of Resident 9's facility document titled, "FALL RISK ASSESSMENT," indicated an assessment date of August 1, 2016. Resident 9's fall risk score was documented as a total score of 22. The document further indicated, "IF the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan." After further record review, no prevention protocol was found on Resident 9's care plan.
The facility document titled, "Physician's Orders," for Resident 9, dated August 2016, was reviewed. The document indicated on August 1, 2016, an order for "XERALTO (sic) (blood thinner) 20MG (milligram) PO (by mouth) Q5PM (at five in the evening) for A-FIB." There was an additional order to, "MONITOR S/SX (signs and symptoms) OF BRUISING AND BLEEDING."
The U.S Food and Drug Administration (FDA) January 2014, "Summary View," for Xarelto indicated, "WARNINGS AND PRECAUTIONS...Risk of Bleeding: Promptly evaluate any signs or symptoms of bleeding..." The December 2014, "Summary View," indicated, "...addition of thrombocytopenia (bleeding into the tissues, bruising, and slow blood clotting after injury) as an adverse reaction..."
A review of the official website for Xarelto, "Information for Healthcare Professionals," indicated under the heading, "WARNINGS AND PRECAUTIONS...Risk of Bleeding: XARELTO increases the risk of bleeding and can cause serious or fatal bleeding. Promptly evaluate any signs or symptoms of blood loss and consider the need for blood replacement. Discontinue XARELTO in patients with active pathological hemorrhage (escape of blood from blood vessels into surrounding tissue)." It further indicated, "A specific antidote (medicine taken to counteract or cancel another medication) (Xarelto) is not available..."
A review of Resident 9's facility nursing documentation found an entry on August 8, 2016, at 4:19 p.m., that indicated, "...PATIENT FELL IN HALL ON STATION 2 NO VISIBLE INJURIES NOTED, THIS NURSE WITNESS (sic) FALL, AMBULATING WITH WALKER PATIENT APPEARED TO HAVE TRIPPED ON HIS OWN FEET...NEURO CHECK (neurological checks- used to assess level of consciousness in order to determine functionality and or injury. The purpose of a neuro check is to make sure neurological functions were not impaired after a head injury) IN PROGRESS, PLACE ON Q15 (every minute) MONITORING FOR SAFETY..."
Review of Resident 9's facility document titled, "INVESTIGATION FOR ALL INCIDENTS," with a date of the incident documented as August 10, 2016, indicated, "Resident was in dinning (sic) room and fell from chair and hit his head resident assessed already had previous bruising from previous fall..."
A review of the facility form titled, "INCIDENT REPORT," completed for Resident 9 on August 12, 2016, had a handwritten note that indicated, "Incident report completed 8/12/16 By (sic) (license vocational nurse-LVN 7's name)." The incident report indicated, "Resident was in dinning (sic) room and fell from chair and hit head. Assessed Resident and injury noted to R (right) middle forehead in same spot as previous injury d/t (due to) previous fall Bruising and hematoma (a collection of blood, usually clotted, located outside a blood vessel)..." The handwritten note was signed by the Director of Nursing (DON) with his title next to his signature. The signature indicated the DON was aware of the second fall that occurred August 10, 2016, on August 12, 2016.
The facility document titled, "RESIDENT TRANSFER RECORD," dated August 11, 2016, was reviewed. It was indicated by documentation in the section, "Skin and Body Assessment," a bruise to the right side of Resident 9's head.
Review of a facility nursing note dated August 11, 2016, at 10:18 a.m., for Resident 9 indicated, "PATIENT SENT OUT TO HOSPITAL, PER(physician's name) VIA (name of ambulance company) FOR CHANGE OF LOC (level of consciousness)..."
Review of a facility nursing note dated August 11, 2016, at 3:39 p.m., for Resident 9 indicated, "RELATED TO PATIENT STATUS POST FALL, ADMITTED TO (hospital name)..."
On August 22, 2016, at 12:03 p.m., an interview was conducted with the DON. The DON was asked if Resident 9 had had a witnessed fall. The DON stated, "Yes." The DON was asked where the fall had occurred. The DON stated in the hall. The DON was asked if the resident had had any visible signs of bruising after the fall. The DON stated, "No." The DON was then asked why a resident who was on a blood thinner would not have been sent out to the hospital if there was possibility of a head injury that occurred during the fall. The DON stated that just because a resident was taking a blood thinner was not a reason to send the resident out for evaluation. The DON further stated it was up to the physician to send the resident out to the hospital for evaluation. The DON stated again, just because a resident was on a blood thinner and hit his head was not necessarily a reason to send a resident out for evaluation. The DON was asked if the physician had been notified of Resident 9's fall, the DON stated, "Yes," and stated that 72 hour "neuro checks" had been ordered.
On August 22, 2016, at 1:28 p.m., a phone interview was conducted with LVN 6 who had observed Resident 9's fall on August 8, 2016. LVN 6 was asked about Resident 9's fall on August 8, 2016. LVN 6 stated she observed the resident place his walker against the wall, then proceed to trip over his own feet and fall. LVN 6 was asked if she observed Resident 9 hit his head. LVN 6 stated, "No," she had not seen him hit his head. LVN 6 was asked if she had observed any bruising on Resident 9's head. LVN 6 stated she had been off work August 9th and 10th and had not seen the bruising until she had returned to the facility on August 11, 2016.
LVN 6 stated she had not been made aware of any falls after the August 8, 2016, fall.
On August 22, 2016, at 1:39 p.m., a second interview was conducted with the DON. The DON was asked if there was any documentation or if he had received any notification of a fall after the August 8, 2016, fall that would have occurred prior to Resident 9 being sent out 911 (paramedic ambulance) on the morning of August 11, 2016. The DON stated there was no documentation of a fall witnessed or unwitnessed after the August 8th fall. The DON further stated he had not been notified of any falls after Resident 9 had fallen on August 8, 2016.
On August 25, 2016, at 9:41 a.m., a second interview was conducted with LVN 6. LVN 6 was asked when the last time she had seen Resident 9. LVN 6 stated before she had left for the day on August 8, 2016, at approximately 2:30 p.m. When asked if she had identified any injury to the residents head, LVN 6 stated it was a little red. LVN 6 stated when she returned to work on August 11, 2016, after being off for two days, she had observed the bruising to Resident 9's head. LVN 6 stated no one had reported the bruise on the resident's head to her. LVN 6 stated that on August 11, 2016, the resident could not move or talk. LVN 6 further stated after the resident had been sent out to the hospital via 911 she had called other staff members at the facility to find out what had happened to the resident. LVN 6 stated no one could tell her what had happened to the resident in her absence. LVN 6 stated that something had to have happened to the resident between August 10th and the 11th.
On August 25, 2016, at 5:12 p.m., a phone interview was conducted with a paramedic who had transported Resident 9 from the facility to the acute hospital after the facility had called 911(emergency phone number to call for paramedic staff) on XXXXXXX, 2016. The paramedic stated the resident had an altered mentation (confused) and had "incomprehensible (unable to understand) and garbled (unclear) speech." The paramedic further stated two facility staff members had assisted him in the resident's room but neither of the staff was able to state what had caused the bruise on Resident 9's head. The paramedic stated the bruise on Resident 9's forehead had a yellow aura around it which indicated it had begun healing. The paramedic stated the bruise on the resident's head was, "Difficult to miss."
Resident 9's paramedic ambulance report titled, "PATIENT CARE REPORT," dated August 11, 2016, was reviewed. The report indicated, "...PT. (patient) NOTED TO BE IN UNKEPT ROOM. STAFF REPORTS FINDING PT. TO BE MORE ALTERED THAN BASELINE AS WELL AS FEBRILE (with a fever) EMS (emergency medical services-paramedic) NOTES MULTIPLE BRUISES TO BOTH PT. KNEES, ELBOWS AND FOREHEAD ABOVE RIGHT EYE. COLOR INDICATES BRUISES ARE FROM A FALL THAT OCCURRED YESTERDAY, HOWEVER PT. WAS NOT TRANSPORTED TO ED (emergency department) FOR EVAL (evaluation) PT. FOUND TO BE ALTERED...BASE (Base Station- a radio used for two-way conversation between the transporting paramedic ambulance and hospital emergency room personnel) CONSULTED DUE TO NATURE OF PT. INJURIES, ADVISED TO CONTINUE TO CLOSEST ED (Emergency Department)...REPORTS GIVEN TO ED RN (registered nurse) AND MD (physician) AT BEDSIDE DUE TO CONCERNS WITH PT. CARE AT FACILITY..." Further review of the report indicated under heading, "PHYSICAL ASSESSMENT," the forehead was, "POSITIVE: CONTUSION (region of injured tissue or skin in which blood capillaries have been ruptured) ECCHYMOSIS (bruising discoloration of the skin resulting from bleeding underneath) AND EDEMA/SWELLING- TRAUMATIC..."
On August 26, 2016, at 3:10 p.m., a phone interview with the DON and facility Administrator indicated a certified nurse's assistant (CNA 1) had observed Resident 9 fall from a wheelchair in the dining room on August 10, 2016, and that an LVN charge nurse (LVN 7) had been notified of the fall. The DON stated LVN 7 had not documented the incident.
On August 26, 2016, at 4:00 p.m., a phone interview was conducted with LVN 7. LVN 7 stated Resident 9 had been sitting in an oversized wheelchair that had belonged to another resident and was moved to a different wheelchair that was tilting. LVN 7 stated Resident 9 was leaning forward in the wheelchair so she and another nurse went to find a more suitable wheelchair for Resident 9. LVN 7 stated when she had returned to the dining room with another wheelchair a CNA (CNA 1) had informed her that Resident 9 had fallen, "again." LVN 7 stated CNA 1 told her that Resident 9 had hit his head again on the same side as the day before. LVN 7 was asked what side of Resident 9's head had been injured. LVN 7 hesitated briefly and then stated the right side-"Yes, right side." LVN 7 stated there was no observed cut or bleeding on the resident's forehead. LVN 7 was asked if she had documented the incident. LVN 7 stated she had completed an "Incident Report," but stated she had not documented the fall. LVN 7 stated she had informed other staff members about Resident 9's fall.
On August 29, 2016, at 1:57 p.m., a phone interview was conducted with CNA 1. CNA 1 was asked if he had witnessed Resident 9 fall. CNA 1 stated he had observed Resident 9 fall from his wheelchair in the dining room but was unable to remember the date of the fall. CNA 1 stated Resident 9 had leaned forward in his wheelchair and had fallen completely out of the wheelchair and had hit his head. CNA 1 stated he had informed the charge nurse (LVN 7). CNA 1 stated Resident 9 had landed on the right side of his head. CNA 1 stated that he had assisted the resident back into his wheelchair and had observed a "red bruise," on Resident 9's head and stated it appeared more like, "internal bleeding" because he "fell a little bit too hard." CNA 1 stated he was the only staff member that had observed the fall, but stated again that he had informed the charge nurse (LVN 7) of the fall.
On August 29, 2016, at 4:40 p.m., a phone interview was conducted with CNA 2. CNA 2 was asked about Resident 9. CNA 2 stated she had seen the resident on August 10, 2016, the day before he had been sent out to the hospital. CNA 2 stated she had assisted a charge nurse (LVN 7) move Resident 9 from one wheelchair to another wheelchair in the dining room after LVN 7 had informed her and another CNA that the resident had fallen. CNA 2 stated LVN 7 had asked her to assist the resident back to his room. CNA 2 was asked if she had observed any bruising on Resident 9's head. CNA 2 stated she had observed a circular bruise above his left eye. CNA 2 stated she believed it was the left eye. CNA 2 was then asked if she had seen Resident 9 again that day. CNA 2 stated, "No," she further stated, "I thought she (LVN 7) was going to take care of everything."
Review of the facility's policy and procedure titled, "POLICY AND PROCEDURE ON FALL PREVENTION AND REDUCTION," undated indicated, "If and when fall (sic) occurs, facility shall implement corrective measures to reduce incidence of fall." The policy further indicated, "...6. Residents with fall incident shall be referred to appropriate healthcare professionals. 7. Licensed nurse shall immediately complete an incident report and incident investigation report relating to the fall incident." The policy indicated under heading, "COMPONENTS OF A FALL REDUCTION PROGRAM," section I, "Monitoring & Reporting of Fall Incidences- each staff must report all incidents he or she is involved in or witnesses to, to (sic) his or her immediate supervisor...Residents identified to be at greater risk for falls or further falls should be monitored closely to prevent further occurrence of fall incident."
Review of Resident 9's acute hospital record title, "HISTORY AND PHYSICAL-STANDARD HOSPITAL ADMIT," (H&P) dated August 11, 2016, indicated, "...Patient (Resident 9) presents with: ALTERED LEVEL OF CONSCIOUSNESS (ALOC)...Called (facility phone number) busy signal. Noted with head bruise and per nurse, facility states he had fallen there." Further review of this document indicated, "EMERGENCY DEPARTMENT COURSE/INTERIM INTERVENTIONS: had CT (CAT scan- computed tomography-radiologic imaging that uses computer processing to generate an image) with Impression as follows: Acute left subdural hematoma (a clot of blood that develops between the surface of the brain and the brain's outer covering, due to stretching and tearing of veins on the brain's surface. These veins rupture when a head injury suddenly jolts or shakes the brain) measuring up to 2.4 cm (centimeter or approximately 1 inch) overlying the left parietal lobe (one of four major lobes of the brain)." The H&P indicated, "Patient Active Problem List: SUSPECTED ADULT NEGLECT." Section titled, "ASSESSMENT AND PLAN-PROBLEM LIST," indicated, "Active Problems:...ALOC---unclear source, possibly due to Subdural hematoma from fall...Due to bleed no LP (lumbar puncture--procedure of taking cerebrospinal fluid from the spine in the lower back through a hollow needle)...TRAUMATIC SUBDURAL HEMATOMA--patient on Xarelto per nursing facility notes. Give Kcintra (a medication given to stop bleeding) for helping with bleed...on Xarelto, hold medication due to bleed..."
The hospital's operating room surgeon note dated August 12, 2016, for Resident 9 indicated, "...bruises found all over his body..."
Resident 9's acute hospital progress note dated August 18, 2016, at 5:30 a.m., indicated, "PHYSICAL EXAM: GENERAL: disheveled, unkept, ill appearing...SKIN: multiple bruises..."
Review of the acute hospital's progress note for Resident 9 dated August 18, 2016, also at 5:30 a.m., by a different physician indicated in section, "HPI (history of present illness)...On Neurosurgery examination patient...was taken to the OR (operating room) emergently for Left Craniotomy (The University of Rochester Medical Center Neurosurgery defines craniotomy as a neurosurgical procedure that involves removing a portion of the skull in order to relieve pressure on the underlying brain. The procedure is typically done in cases where a patient has experienced a very severe brain injury that involves significant amounts of bleeding around the brain or excessive swelling of the brain, typically performed as a life saving measure) for evacuation of subdural hematoma by (name of physician) on 8/12/2016."
A review of a hospital critical care progress note for Resident 9, dated August 18, 2016, indicated, "HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE:...(Resident 9's name)...who was admitted for fall with multiple trauma including head trauma resulting in subdural hematoma. Patient was taken emergently for evacuation of hematoma..." The note further indicated, "...Given poor prognosis (outcome) for meaningful neurological recovery per neurology and neurosurgery, requested Bioethics (committee which supports hospitals in providing clinical ethics discussions such as withholding and withdrawing life-sustaining treatments for a patient) consult regarding guidance on goals of care, since patient has no family member or decision maker."
A hospital progress note for Resident 9 dated August 18, 2016, at 8:47 a.m., indicated, "Persistent ALOC...-MRI (magnetic resonance imaging- scan that uses magnetism, radio waves, and a computer to produce images of internal body structures) brain showed large right MCA (Middle cerebral artery) stroke, which may explain patient's ALOC..." The note further indicated, "Patient remains in critical condition requiring constant attention..."
A hospital progress note for Resident 9 dated August 20, 2016, indicated, "Patient is on comfort care only status. This is due to poor prognosis following left craniotomy for evacuation of subdural hematoma 8/12/16..." Further review of the note indicated, "Care conference (sic) had with (contact's name) regarding the patient's poor clinical status and prognosis. Decision was made to proceed with comfort measures only. Pt (patient) extubated (removal of a tube used to help with breathing) and placed on morphine (medication to treat severe pain) gtt (drip)."
Review of a hospital progress note for Resident 9 dated August 20, 2016, at 12:11 p.m., indicated, "Called by RN (registered nurse) to bedside to assess the patient. Patient's rhythm on telemetry (machine used to monitor changes in blood pressure and the rate and rhythm of the heart) noted to be asystole (flatline). The patient was then examined by a physician. Pupils were fixed and dilated (pupils do not respond or react to light when shined into the eye; fixed and dilated pupils indicate no chance of survival). No spontaneous respirations (breathing) observed. No heart sounds were auscultated (heard)...Patient pronounced dead at 8/20/2016 (sic) 1200."
Therefore, the facility's failure to ensure Resident 9 received treatment and care in accordance with professional standards of practice by not completing accurate assessments of the resident's head injuries after two falls. Resident 9 required transportation to an acute care hospital's emergency department by paramedic ambulance where he underwent emergent brain surgery and ultimately died nine days later. The facility failure to accurately assess Resident 9's head injuries resulted in the resident not receiving essential medical attention for life-saving interventions.
The above violation presented either an imminent danger that death or serious harm would result or a substantial probability of death or serious physical harm to the patient. |
| 910000003 |
ROSECRANS CARE CENTER |
910010128 |
B |
06-Sep-13 |
None |
4553 |
72315 Nursing Service-- Patient Care (b) Each patient shall be treated as an individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. Based on interview and record review, the facility failed to ensure Patient A was free from physical abuse from Patient B who was known to have physical and verbal abusive behavior toward others (staff and patients). On January 30, 2011, Patient A was hit twice by Patient B with a cup and suffered an abrasion and contusion to the forehead. On February 10, 2011, at 9:45 a.m., an unannounced visit was conducted to investigate a complaint allegation that Patient A was hit twice in the head by Patient B.A review of the clinical record indicated Patient A was readmitted to the facility on August 17, 2008, with diagnoses that included Parkinson's disease (a progressive nervous disorder marked by symptoms of trembling hands, lifeless face, monotone voice, and a slow shuffling walk), dementia (significant loss of intellectual abilities), and osteoporosis (thinning of the bones). The Minimum Data Set (MDS) an assessment and care screening tool, dated August 28, 2010, indicated Patient A's cognition was severely impaired and dependent on staff for all areas of activities of daily living and assessed as having no behavioral problems.A review of the Licensed Nurse Progress notes dated January 30, 2011, at 3:50 p.m., revealed Patient A was hit in the forehead with a hard plastic coffee cup by another patient (Patient B). It was documented that Patient A was hit twice and was assessed as having slight elevation of the skin, slight redness and no skin tear or laceration noted. The family and physician were notified of the incident. The physician gave an order to apply an ice pack on Patient A?s forehead for 20 minutes every one to two hours as needed for swelling. On January 30, 2011, at 4:45 p.m., Patient A was transferred to a general acute care hospital (GACH) for treatment. A review of the emergency room progress note dated January 30, 2011, indicated Patient A was hit in the head with a cup and suffered a contusion to the forehead. A review of Patient B?s clinical record indicated he was admitted to the facility on April 3, 2009, with diagnoses that included mental retardation (general learning disability or intellectual disability), psychosis (loss of contact with reality) and depression. The Minimum Data Set (MDS) an assessment and care screening tool, dated January 13, 2011, indicated the patient's cognition was moderately impaired and decision-making were poor. The patient was assessed as having physical and verbal behavioral symptoms directed toward others and other behavioral symptoms such as hitting or scratching self, and pacing. Patient B required limited assistance on staff with his activities of daily living. The Licensed Nurses Progress notes dated January 13, 2011, at 4 p.m., indicated Patient B grabbed a nurse by the hair on January 15, 2011 at 4:15 p.m. Patient B was in the activity room and was observed screaming, yelling, throwing objects and pushing staff. There was another incident on January 16, 2011 at 9:50 a.m., that Patient B grabbed another patient by the hair. The physician was notified and ordered medication to calm the patient down.When interviewed on February 11, 2011 at 2:30 p.m., the Director of Nurses (DON) stated Patient B had developed behavioral problems in January of 2011. When asked if there was a plan of care developed for the resident?s behavioral problems, she stated there should have been one developed, however she was unable to locate one in the clinical record. She stated that on January 30, 2011, Patient B became angry because he could not have cookies off the activity cart. He turned around to Patient A and just hit him twice in the forehead with the plastic coffee cup. The patients were immediately separated and the physicians were called. Patient B had the behavior of screaming and hitting and she had been trying to place Patient B in another facility but because he was mentally challenged, she was having a difficult time.The facility failed to ensure Patient A, residing in the facility, was afforded the right to be free from physical abuse from Patient B who was known to have physical and verbal abusive behavior toward others (staff and patient). On January 30, 2011, Patient A was hit twice by Patient B with a cup and suffered an abrasion and contusion to the forehead. The violation had a direct relationship to the health, safety or security of Patient A. |
| 910000003 |
ROSECRANS CARE CENTER |
910011677 |
AA |
17-Nov-15 |
9LQB11 |
24281 |
F309 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 psychological well-being, in accordance with the comprehensive assessment and plan of care.F 329 ?483.25(l) Unnecessary Drugs 1. General. Each resident?s drug regimen must be free from unnecessary drugs: (i) In excessive dose (including duplicate therapy); or (ii) For excessive duration; or (iii) Without adequate monitoring; or (iv) Without adequate indications for its use; or (v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (vi) Any combinations of the reasons above. 2. Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that: (i) 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 (ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.On October 23, 2013 at 8:15 a.m., an unannounced visit was conducted to investigate a complaint alleging Resident 1 was over-medicated and over-sedated. Resident 1 became unresponsive and the facility called 911 (emergency phone number). Resident 1 passed away in the facility.Based on interview, and record review, the facility failed to: 1. Ensure Resident 1, who received Risperdal (antipsychotic), Cogentin (anticholinergic), Depakote (anticonvulsant), and Ativan (antianxiety) was assessed and monitored for medications side effects such as sedation (sedative drug that produce a state of calm or sleep), hypotension (a drop in blood pressure due to a change in body position when a person moves to a more vertical position: from sitting to standing or from lying down to sitting or standing), and drowsiness (sleepiness) as indicated in the plan of care. 2. Ensure Resident 1, had specific clinical justification for the use of Risperdal. 3. Ensure Resident 1 did not received Ativan 2 milligram more often than every six hours as ordered by the physician on September 30, 2013, at 10:30 a.m., and 2:30 p.m., October 4, 2013, at 4:30 a.m., and 8 a.m., October 5, 2013, at 8 p.m., then October 6, 2013, at 1 a.m. 4. Ensure Resident 1 received Duoneb (breathing treatment used to relax muscles in the airways and increase air flow to the lungs.) every four hours around the clock as ordered by the physician.The facility failures resulted in Resident 1 receiving Ativan 2 mg on three occasions more often than prescribed from September 30, 2013 through October 6, 2013 concomitantly (together) with Risperdal, Cogentin, and Depakote, without adequate monitoring for additive CNS-depressant effects that included, sedation, respiratory depression, ataxia (loss of voluntary muscle control), drowsiness, and weakness, in which the risk of side effects are increased when two or more CNS depressants are administered concomitantly. Resident 1 was not administered DuoNeb breathing treatments on 16 out of 32 occasions from October 2-7, 2013, which included 2 doses not being administered on October 7, 2013 at 12 a.m. and 4 a.m.These violations resulted in Resident 1 being found on October 7, 2013, at 6:05 a.m., unresponsive and no vital signs (signs of life; specifically: the pulse rate, respiratory rate, body temperature, and often blood pressure of a person), cardiopulmonary resuscitation (CPR) was started, and paramedics were called. At 6:49 a.m., Resident 1 was pronounced dead, in the facility.A review of Resident 1's closed clinical record (Face Sheet) indicated Resident 1 was a 72 year-old female, who was initially admitted to the facility on September 8, 2010, and was readmitted on September 27, 2013 with diagnoses that included acute renal insufficiency (when the kidneys suddenly become unable to filter waste products from the blood) with hemodialysis treatment (a procedure for removing waste products and free water from the blood), diabetes mellitus (high blood sugar), hypertension (high blood pressure), and dementia with psychosis (a decline of mental abilities such as thinking, reasoning, and memory/feature of mental illness typically characterized by radical changes in personality, impaired functioning). Resident 1's Minimum Data Set (MDS, an assessment and care screening tool), dated September 23, 2013, indicated Resident 1 had short term memory problem, cognitive skills for daily decision-making were moderately impaired, and required supervision with transfer and toilet use, limited assistance with walking, dressing, and personal hygiene.A care plan, dated September 25, 2013, for needs of antipsychotic (Risperdal) medication for psychosis manifested by non-compliance to care and stealing other resident's and facility's belongings, indicated the resident was at risk for side effects from the medication, and risk for falls. The goals included no side effects from the medication every shift. The plan approaches included to monitor side effects from the medication and to notify the physician if side effects were observed. The antipsychotic sticker pasted on the care plan indicated to observe the resident closely for significant side effects, common sedation, drowsiness, dry mouth and postural hypotension. Another care plan dated September 25, 2013, for needs of Depakote (anticonvulsant) medication as mood stabilizer for psychosis manifested by mood swings, indicated the resident was at risk for side effects from the medication and at risk for falls. The plan approaches included to monitor side effects from the medication and to notify the physician if side effects were observed. The Depakote sticker pasted on the care plan indicated the adverse side effects which included drowsiness.Resident 1?sphysician's medication orders included the following: 1. Norvasc 10 milligram by mouth (mg) every day, ordered September 8, 2010, for hypertension. The order did not have blood pressure hold parameters (Taking of vital signs, upon which administration of medication or treatments are conditioned). 2. Aricept 5 mg by mouth every night, ordered September 8, 2010, for dementia 3. Cogentin 1 milligram (mg) by mouth to be given every 12 hours, ordered April 23, 2011, for extrapyramidal symptoms (EPS, involuntary muscle movement.) 4. Depakote 500 mg by mouth every 12 hours, ordered April 23, 2011 for mood swings and psychosis. 5. Losartan 50 mg by mouth every day, ordered October 24, 2011, for hypertension with a parameter to hold if systolic blood pressure (SBP, is the top number of the blood pressure) is less than 110 millimeters of mercury (mmHg). 6. Risperdal 1 mg by mouth every night, ordered July 24, 2013, for resident's non-compliance to care and stealing other residents? and facility's belongings7. Ativan 2 mg by mouth every six hours as needed (PRN) for agitation, ordered September 27, 2013 8. Duoneb 3 milliliter (ml) via nebulizer every four hours around the clock (ATC) for shortness of breath and/or wheezing and every two hours PRN, ordered September 27, 2013 9. Nicoderm CQ 21 mg per 24 hours transdermal patch daily, apply one patch to upper outer arm or chest for smoke cessation, ordered September 27, 2013.Resident 1 had a physician's order dated September 27, 2013, for hemodialysis treatment on Monday, Wednesday and Friday. A review of Dialysis Record indicated Resident 1 last dialysis treatment was on October 4, 2013. A review of the Medication Administration Record (MAR), and Narcotic and Hypnotic Controlled Record from September 28, 2013 to October 6, 2013, indicated Resident 1 received Ativan 2 mg for agitation on the following dates and times: 1. September 28, 2013, at 5 a.m., and 6 p.m. 2. September 29, 2013, at 12:15 a.m. and 3:30 p.m. 3. September 30, 2013, at 12:20 a.m., 10:30 a.m., and 2:30 p.m. 4. October 1, 2015, at 3 a.m., 11:30 a.m., and 11:30 p.m. 5. October 2, 2015, at 8 p.m. 6. October 3, 2015, at 2 a.m., 11 a.m., and 5 p.m. 7. October 4, 2013, at 4:30 a.m., 8 a.m., and 6 p.m. 8. October 5, 2013, at 8 a.m., and 8 p.m. 9. October 6, 2013, at 1 a.m., and 3 p.m.The MAR and Narcotic and Hypnotic Controlled Record indicated Resident 1 received 21 doses of Ativan 2 mg in nine days upon readmission. Also, on September 30, 2013, October 4, 5, and 6, 2013, Resident 1 was given three doses of Ativan 2 mg more often than every six hours as needed (PRN) as prescribed by the physician.A review of the Psychotropic Assessment for Ativan, dated September 27, 2013, indicated for the first, second and third day to document non-pharmacological interventions (approaches to care that do not involve medications, such as behavioral interventions, including direct care and activities, that are provided as part of a supportive physical and psychosocial environment, and are directed toward preventing, relieving, and/or accommodating a resident?s distressed behavior), and to indicate effectiveness of the non-pharmacological interventions. There was no written documentation that non-pharmacological interventions for the first, second and third day were attempted.A review of Resident 1?s MAR under behavior indicated to monitor episodes of stealing other residents? or facility?s belongings every shift, tally by hash marks. A review of behavior hash mark for the months of July, August, September, and October 2013 indicated no behavior episodes except for three hash marks on August 18, 21, and 23, 2013 during the 3 p.m. to 11 p.m. shift. There was no documentation that the resident?s level of sedation, drowsiness and dry mouth are being monitored for the use of Risperdal. There was no documented clinical justification and indication for the continued use of Risperdal for Resident 1 who had dementia with psychosis.According to DailyMed, the FDA approved manufacturer's label for Risperdal has a Black Box Warning that indicates, "Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death...most of the deaths appeared to be either cardiovascular (e.g. heart failure, sudden death)... Risperdal (risperidone) is not approved for the treatment of patients with dementia-related psychosis...The most common adverse reactions were nausea, somnolence (sleepiness), sedation, vomiting, dizziness, and akathisia (agitation and restlessness)...there was a 20% increase in valproate (Depakote) peak plasma concentration (the highest level of drug that can be obtained in the blood usually following multiple doses), after concomitant administration of Risperdal.The Licensed Personnel Weekly Progress notes dated September 28, 2013, at 4:40 a.m., indicated the resident was found in her room, sitting on the floor. The late entry dated September 28, 2013, at 9 a.m., indicated the resident had a skin tear, measured 1.5 centimeters (cm) to 2.0 cm to her left shoulder. There were no vital signs taken, to assess and identify if the resident had low blood pressure at the time of the fall.The Licensed Personnel Weekly Progress notes dated September 29, 2013, at 12 a.m.(Midnight)., indicated certified nursing assistant found Resident 1 in her room sitting on the floor with no injuries. The documentation indicated the resident was agitated and was given Ativan 2 mg, with no effectiveness. Resident 1?s vital signs were taken and documented within normal ranges.The Licensed Personnel Weekly Progress notes, dated September 29, 2013, at 11:30 a.m., indicated the facility's maintenance staff reported Resident 1 was lying on the floor, face down. The documentation indicated the resident was bleeding from her left, inner nostril (nose) due to a skin tear and complained of face pain, and the pain scale was 4/10 (ten being the worst pain a resident can experience). First aid was administered, the physician was notified. The vital signs were taken and documented within normal range.The Interdisciplinary Team (IDT) notes, dated September 30, 2013, indicated Resident 1 recently returned to the facility from the general acute care hospital and was really weak, in addition to starting hemodialysis three times a week. The IDT continued to summarize Resident 1 was at a high risk for repeated falls due to fall history, medications, and diagnoses. The record further indicated the hemodialysis treatment started on September 30, 2013. There was no documentation that the IDT assessed the resident for potential side effects of medications that contributed to her three fall incidents.A review of Resident 1?s Licensed Personnel Weekly Progress notes from May 2013 through October 2013 documented falls on: * May 20, 2013 at 12 a.m., * June 6, 2013 at 1:30 a.m., * September 28, 2013 at 4:40 a.m., * September 29, 2013 at 12 a.m. and * September 29, 2013 at 11: 30 a.m. Resident 1?s Licensed Personnel Weekly Progress notes indicated a pattern of falls during the night and early morning, with no documentation of hourly monitoring or any actions taken to prevent such falls.According to DailyMed, the FDA approved manufacturer's label for Risperdal indicated monitoring of orthostatic vital signs should be considered in patients for whom this is of concern. A dose reduction should be considered if hypotension occurs. Risperidone should be used with particular caution in patients with known cardiovascular disease (history of myocardial infarction or ischemia, heart failure, or conduction abnormalities), cerebrovascular disease, and conditions which would predispose patients to hypotension, e.g., dehydration and hypovolemia. Clinically significant hypotension has been observed with concomitant use of risperidone and antihypertensive medication.The facility undated policy and procedures for Fall Prevention and Interventions indicated monitor the resident frequently especially during the time of day or during circumstances in which resident has established pattern of falls, to assess the medications for side effects such as confusion, dizziness orthostatic hypotension and reduce or change medications as appropriate.The Licensed Personnel Weekly Progress notes, dated October 6, 2013, at 11:30 p.m., indicated that Resident 1 was in bed, sleeping soundly on her back but easily aroused. The notes indicated on October 7, 2013 at 1:30 a.m., certified nursing assistant (CNA) provided care, as tolerated and repositioned the resident. At 3:30 a.m., the notes indicated routine positioning and turning was provided by CNA to the resident, and breathing treatment was offered but the resident was too sleepy to tolerate the treatment. The documentation indicated no labored breathing exhibited. The documentation at 5:00 a.m., indicated last rounds, the resident was visually checked and seen moving her extremities, breathing deep but shallow. The documentation at 6:05 a.m. indicated the resident was unresponsive, vital signs were unappreciable, and cardiopulmonary resuscitation (CPR) was started, paramedics were called. At 6:15 a.m., the paramedics came and continued with CPR. At 6:49 a.m., the documentation indicated the resident expired at the facility. A review of the Los Angeles County Fire Department Emergency Medical Service Report Form, dated October 7, 2013, indicated the paramedics were dispatched to the facility at 6:19 a.m., arrived at 6:24 a.m., at resident by 6:26 a.m. (Eleven minutes discrepancy of the facility?s documentation to the time the paramedics took over care of the resident). The documentation indicated cardiac arrest (is the sudden, abrupt loss of heart function), CPR was started right away, and at 6:30 a.m., vital signs indicated blood pressure (BP) zero, pulse rate zero, and respiration zero. The resident was pronounced dead at 6:49 a.m., on October 7, 2013.A review of a death certificate, dated October 7, 2013, indicated Resident 1 died of cardiac arrest, end stage renal disease (ESRD), and hypertensive heart disease.On October 22, 2013, at 3:50 p.m., a telephone interview was conducted with FM1, who stated he and another family member visited Resident 1 on October 2, 2013. FM 1 stated, ?She looked knocked out and had just returned from dialysis, her eyes were glassy and she was half out of it, really sedated." FM1 stated he went to the nurse's station to get someone to look at Resident 1, and approximately seven minutes later a nurse came and after looking at Resident 1, she told himResident 1 looked like that because of receiving dialysis. FM1 stated a facility staff member started to try and feed the resident while she was half asleep. That was the last time he saw the resident alive and was told she was found unresponsive in her bed about 6 a.m. on October 7, 2013. FM1stated, "I didn't understand how that could have happened, if she was being checked often."On October 23, 2013, at 12 p.m., during an interview, the director of nursing (DON) while reviewing Resident 1's clinical records stated Resident 1 was very weak and kept trying to get up, out of the wheelchair, so the resident was moved closer to the nurses' station to be monitored more closely. The DON stated the practice was to monitor Resident 1 every hour to prevent falls. However, the DON stated this was done informally, "We have no evidence of monitoring ... We do not document monitoring." The DON stated that there was no reason to monitor Resident 1 if she was not getting out of bed. The DON stated while the resident was in bed, the resident was being checked if she was breathing. The DON was unable to provide documentation that Resident 1 was observe closely for significant medications side effects such as sedation, drowsiness, and postural hypotension as indicated in the Risperdal care plan.On October 23, 2013,at 3:10 p.m., licensed vocational nurse 3 (LVN 3) stated he gave Resident 1 Ativan 2 mg on October 6, 2013 at 3 p.m., because the resident was trying to get out of bed. LVN 3 stated he checked the resident every hour to make sure the resident would not fall because the resident was so weak. LVN 3 stated he was not monitoring Resident 1 for sedation side effects from the medication, and stated he was monitoring the resident to prevent fall. On October 24, 2013 at 6:50 a.m., during an interview, licensed vocational nurse (LVN 2) stated on October 6, 2013, during her rounds at 11:30 p.m., the resident was asleep. LVN 2 stated when she offered the resident her breathing treatment (Duoneb) at midnight, as prescribed every four hours; she stated the resident usually refused. LVN 2 stated she marked the MAR that resident refused although the breathing treatment was not offered. LVN 2 stated she noticed Resident 1 was not calling, during the night and in the morning of October 7, 2013, so she went to check the resident at 6:05 a.m., and the resident was found unresponsive. LVN 2 stated she called the certified nursing assistant 1 (CNA 1) for help and she checked the resident's pulse and there was nothing and CODE BLUE (a medical emergency, when a resident's heart stops beating or her lungs stop functioning) was called.A review of Resident 1?s MAR revealed no documentation that Resident 1 received Duoneb every four hours as ordered by the physician on October 2, 2013, at 8 a.m., 12 p.m., and 8 p.m.; October 3, 2013, at 8 a.m., 12 p.m., 4 p.m., and 8 p.m.; October 4, 2013, at 8 a.m., and 12 p.m.; October 5, 2013, at 12 a.m., 4 a.m., 8 a.m., 12 p.m., and 4 p.m., then October 7, 2013, at 12 a.m., and 4 a.m. Resident 1 did not receive the DuoNeb 16 out of 32 occasions.During an interview, on October 24, 2013 at 7:40 a.m., CNA 1, who worked on 11 p.m. to 7 a.m. shift stated, "I was here when the resident passed, she was on my assignment on October 6 and 7, 2013. I checked the resident when I first came on duty about 11 p.m. to 11:30 p.m. and passed water about 12 a.m., reposition her and changed her diaper about 3 a.m. to 3:30 a.m. Resident 1 was still sleeping. The next time I saw the resident was when LVN 2 called me and a CODE BLUE was called about 6:05 a.m."According to the American Geriatrics Society 2012 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, indicated all benzodiazepines, which includes Ativan (lorazepam), increase risk of cognitive impairment, delirium, falls, fractures?in older adults and should be avoided for the treatment of insomnia, agitation, or delirium. The quality of the evidence is high and the strength of the recommendation is strong.According to DailyMed (the official web-based provider of FDA medication labeling information, or package inserts), indicated Ativan use in elderly or debilitated patients, initial dose should not exceed 2 mg; Over dosage of Ativan, a benzodiazepine is usually manifested by varying degrees of central nervous system depression ranging from drowsiness to coma? In more serious cases, and especially when other drugs?were ingested, symptoms may include?hypotension, cardiovascular depression, respiratory depression, hypnotic state, coma, and, death. According to DailyMed, Clinically Significant Drug Interactions? Ativan (lorazepam), produce increased CNS-depressant effects when administered with other CNS depressants such as antipsychotics (e.g. Risperdal)?anticonvulsants (e.g. Depakote)? Concurrent administration of lorazepam with valproate (Depakote) results in increased plasma concentrations and reduced clearance of lorazepam. Lorazepam dosage should be reduced to approximately 50% when co-administered with valproate.According to DailyMed, the FDA approved manufacturer's label for Depakote (valproate) indicated under, Warnings and Precaution, Somnolence (sleepiness) in the Elderly...other adverse reactions (e.g. tremors, dizziness, hypotension, etc...)... Dose reductions or discontinuation of valproate should be considered in patients? with excessive somnolence.According to DailyMed for Cogentin (a highly anticholinergic medication associated with mental confusion, delirium, dizziness, sedation, dry mouth and constipation), used in treating drug-induced extrapyramidal disorders (involuntary muscle movement or tremors) ...The drug may cause complaints of weakness and inability to move particular muscle groupsThe facility failed to: 1. Ensure Resident 1, who received Risperdal, Cogentin, Depakote, and Ativan was assess and monitor for medications side effects that included excessive sleepiness or drowsiness, low blood pressure and respiratory depression as indicated in the plan of care. 2. Ensure Resident 1, had a clear indication for the use of Risperdal. 3. Ensure Resident 1 did not received Ativan 2 milligram more often on three occasions. 4. Ensure Resident 1 received Duoneb on 16 out of 32 occasions from October 2-7, 2013, with two treatments not administered on October 7, 2013 at 12 a.m. and 4 a.m. 5. Ensure Resident 1?s clinical records were accurately documented, prescribed medications were appropriate for the resident with diagnosis of renal failure, and were consistently monitored to minimize medication interactions.The facility failures resulted in Resident 1 receiving an average of 4.5 mg of Ativan each day (over twice the recommended initial total daily dose of 2 mg for elderly or debilitated patients) from September 28, 2013 through October 6, 2013. The excessive doses of Ativan with the decreased clearance due to renal failure and combined use of Depakote, Risperdal, and Cogentin put the resident at greater risk of Ativan accumulation in the system that increased the sedative side effects and respiratory depression. The breathing treatments were not administered as prescribed which contributed to Resident 1 being found unresponsive with no vital signs on October 7, 2013, at 6:05 a.m., and pronounced dead at 6:49 a.m., after unsuccessful CPR.These violations presented an imminent danger to the resident and were a direct proximate cause of the death of the resident. |
| 920000019 |
ROYAL PALMS CONVALESCENT HOSPITAL |
920012244 |
A |
12-May-16 |
Q6QD11 |
11073 |
483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 483.25 ( c ) Treatment/Services to Prevent Pressure SoresBased on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual?s clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.On 12/11/15, at 8:45 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 having Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure sores (a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure) while at the facility.Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and failed to ensure Resident 1, who was admitted to the facility with no pressure sore and was identified as high risk for developing pressure sores, was provided necessary treatment and services to prevent pressure sores and to promote healing when pressure sores developed, including but not limited to: 1. Failure to identify and evaluate risk factors and changes in the resident's skin condition, implement and monitor effectiveness of interventions, and modify interventions as appropriate as indicated in the facility?s policy.2. Failure to turn and reposition Resident 1 every two hours or as often as needed to keep pressure off bony prominences as per plan of care and document the turning of the resident on the 24-Hour Flow Sheet as indicated in the facility?s policy.3. Failure to perform skin assessment during care, dressing change, and at least weekly to identify the development of pressure sores and ensure prompt interventions to promote healing as per plan of care and facility?s policy.4. Failure to evaluate the pressure sore and document at a minimum, the date observed location, staging, size, drainage, pain, wound bed color and type of tissue, and description of the wound edges and surrounding tissue as per facility?s policy.As a result, Resident 1 developed an unstageable pressure sore (full thickness skin or tissue loss with a depth obscured by slough [yellow, tan, gray, green or brown dead tissue in the wound bed]) to the sacrum (a triangular bone in the lower back situated between the two hipbones), a pressure sore Stage I (persistent skin redness) to the right buttock, a pressure sore Stage II (partial thickness skin loss, is superficial and presents as an abrasion, blister or shallow crater) to the left buttock, and a right heel deep tissue injury (DTI - purple or maroon localized area of discolored intact skin or blood - filled blister due to damage of underlying soft tissue from pressure and/or shear). These pressure sores were not identified in the facility, but identified by the general acute care hospital (GACH) where the resident was transferred on 10/7/15. On 12/11/15, a review of the Admission Record indicated Resident 1 was initially admitted to the facility, on 8/23/15 and re-admitted to the facility on 9/4/15, after two days of hospitalization. Resident 1?s diagnoses included muscle weakness, anemia (a condition in which the blood does not have enough healthy red blood cells), and cachexia (weakness and wasting of the body due to severe chronic illness). The Admission Assessment form, dated 9/4/15, indicated the resident had a sacro-coccyx (tailbone) scar. The Minimum Data Set (MDS ? standardized assessment and care planning tool), dated 9/10/15, indicated Resident 1 required extensive assistance with bed mobility (repositioning and turning from side to side) and personal hygiene, was totally dependent with toilet use, was incontinent of bowel function, and had an indwelling urinary catheter (a soft tubing inserted into the bladder to pass urine). The resident was assessed as having no pressure sore or skin breakdown on admission and as having no history of healed pressure sores. A review of the Braden Scale, a tool used in predicting a pressure sore risk, dated 9/5/15, indicated Resident 1?s score was 15, which represented high risk for pressure sores development. According to the Braden Scale form, a score of 17 or below required a weekly skin assessment and documentation in the medical record, but further record review disclosed no documented evidence a weekly skin assessment was performed. A care plan developed, on 9/8/15, for the resident?s high risk for pressure sore development due to incontinence of bowel, poor food intake, and medical condition, had a goal for the resident not to develop skin breakdown. The interventions included turning and repositioning the resident every two hours and as needed, maintaining skin care, using turn or lift sheets to assist with turning and repositioning changes, and assessing skin integrity during care.The weekly Licensed Nurse Progress Record form, dated 9/8, 9/15, and 10/6/15, had no documentation Resident 1 was repositioned every two hours or more often.On 10/3/15, a physician?s treatment order was obtained for a re-opened sacro-coccyx (tailbone) scar. The order indicated daily treatment with an ointment and cover with dry dressing for 21 days. There was no documentation to indicate the origin of the scar. There was no documentation describing the size, color, odor, depth, and presence of drainage or pain. There was no documentation indicating the resident had any other pressure sore or wounds. On 10/7/15, Resident 1 was transferred to a GACH for evaluation of fever and vomiting and to receive blood transfusion. According to the GACH photographic record, dated 10/7 and 10/8/15, Resident 1 was admitted with an unstageable pressure sore to the sacrum, a pressure sore Stage I to the right buttock, a pressure sore Stage II to the left buttock, and a right heel DTI. The pressure sores assessed at the GACH were not identified by the facility?s licensed nurses. According to the facility's undated policy titled, "Policy and Procedures for Wound Management," the pressure sore prevention and treatment program would include identifying patients at risk for developing pressure sores; identifying and evaluating the risk factors and changes in the resident's condition; implementing individualized, comprehensive plan of care to attempt to stabilize, reduce or remove underlying risk factors; monitoring effectiveness of interventions; and modifying the interventions as appropriate.The policy also indicated pressure sores were to be prevented by repositioning the patient every two hours and as needed. A turning schedule was to be followed and documented on the 24hour flow sheet. The policy indicated the facility has a system in place that assures assessments are timely and appropriate; interventions are implemented, monitored and revised as appropriate; changes in condition are recognized, evaluated, reported to the resident?s attending practitioner and other healthcare professionals, i.e., wound nurse, as appropriate. With each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the pressure ulcer wound should be documented. At a minimum, documentation should include the date observed and location, staging, size, exudate and pain if present, and description of the wound bed, edges, and surrounding tissues.Further record review disclosed no documented evidence a 24-our flow sheet indicating the resident was on a turning schedule as per policy. There was no assessment or evaluation of the wound on the sacral area as per policy. On 12/11/15, at 11 a.m., during a record review with the director of nursing (DON) and a concurrent interview, the DON stated Resident 1 was admitted to the facility with redness to the sacrum, coccyx and buttocks. The DON was unable to locate the documentation of Resident 1 having redness and was unable to locate a weekly skin assessment.On 12/11/15, at 11:30 a.m., during a record review with Licensed Vocational Nurse 1 (LVN 1) and a concurrent interview, LVN 1 stated Resident 1 was admitted to the facility with redness to the sacral and coccyx area and the facility?s policy indicated redness should be reported to the physician. During the record review, LVN 1 was unable to locate documentation of Resident 1's redness to the sacro-coccyx area and notification to the physician. LVN 1 also stated skin assessments and repositioning of the resident should be documented.The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and failed to ensure Resident 1, who was admitted to the facility with no pressure sore and was identified as high risk for developing pressure sores, was provided necessary treatment and services to prevent pressure sores and to promote healing when pressure sores developed, including but not limited to:1. Failure to identify and evaluate risk factors and changes in the resident's skin condition, implement and monitor effectiveness of interventions, and modify interventions as appropriate as indicated in the facility?s policy.2. Failure to turn and reposition Resident 1 every two hours or as often as needed to keep pressure off bony prominences as per plan of care and document the turning of the resident on the 24-Hour Flow Sheet as indicated in the facility?s policy.3. Failure to perform skin assessment during care, dressing change, and at least weekly to identify the development of pressure sores and ensure prompt interventions to promote healing as per plan of care.4. Failure to evaluate the pressure sore and document at a minimum, the date observed location, staging, size, drainage, pain, wound bed color and type of tissue, and description of the wound edges and surrounding tissue as per facility?s policy.As a result, Resident 1 developed an unstageable pressure sore to the sacrum, a pressure sore Stage I to the right buttock, a pressure sore Stage II to the left buttock, and a right heel DTI. These pressure sores were not identified in the facility, but identified by the GACH where the resident was transferred on 10/7/15. The above violation presented either (1) imminent danger that death or serious harm to the resident of the Skilled Nursing Facility would result therefrom, or (2) substantial probability that death or serious physical harm to the resident of the Skilled Nursing Facility would result therefrom. |
| 920000019 |
Royal Palms Post Acute |
920012888 |
A |
25-Jan-17 |
57R511 |
15237 |
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 11/23/16, at 6:45 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 missing from the facility for about seven hours, found by police, and transferred to a general acute care hospital (GACH). 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 to prevent accidents and injuries, including: 1. Failure to ensure Resident 1, who verbalized in multiple occasions she wanted to go to another healthcare setting or go home, was re-assessed for wandering and elopement risk (wandering is moving about without a definite destination or purpose, wandering can be dangerous when the person goes in areas with unsafe conditions such as heavy traffic, crime, and extreme climates. The most dangerous form of wandering is elopement in which the confused person leaves an area and does not return). 2. Failure to develop a comprehensive plan of care for wandering/elopement risk with interventions including supervision and monitoring device to ensure Resident 1?s safety and prevent Resident 1 from leaving the facility without staff knowledge. 3. Failure to implement Resident 1?s plan of care intervention including re-directing attention, encouraging activity attendance, and listening to concerns to attempt reassurance and divert the resident?s attention. 4. Failure to develop comprehensive policies and procedures for wandering and elopement prevention including the use of a signaling device to alert staff when residents attempt to leave the facility and updating the wandering assessment form. As a result, on the night of 11/17/16, Resident 1 eloped from the facility; the police found her the next day in the early morning lying on a sidewalk complaining of being cold. Resident 1 was transported to GACH 1 where she was diagnosed with hypothermia (abnormally low body temperature), shortness of breath, and exacerbation (worsening) of chronic obstructive pulmonary disease (COPD - a chronic lung disease which makes it hard to breathe). A review of the admission record indicated Resident 1 was admitted to the facility on XXXXXXX with diagnoses included dementia (decline in mental ability severe enough to interfere with daily life), COPD, and schizophrenia (is a severe mental disorder in which people interpret reality abnormally). The resident was admitted with orders for psychotropic medications (medications that alter the mind, emotions and behavior) including Zyprexa for paranoia (irrational and obsessive distrust of others), Depakote for poor impulse disorder and Trazadone for lack of sleep. According to an "Assessment for Wandering" form dated on admission XXXXXXX the resident did not meet the criteria (was not a risk for wandering) to follow the procedures for wandering precautions and/or wander guard bracelet (a Wander Guard wristband is a signaling device that will alarm when the resident goes through exit door). A plan of care developed on 9/17/16, for the resident's use of psychotropic medication due to depression, sleep disorder, and psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), included in the interventions: approaching the resident calmly, re-directing her attention, encouraging activity participation, listening to any concerns, and talking to resident during care. According to the Psychosocial Assessment form dated 9/19/16, completed by a social services staff, Resident 1 was insistent she belonged to a psychiatric unit and wanted to go there (warning signs of wandering include verbalizing desire to go somewhere else). There was no documented plan of care developed addressing the resident's risk for wandering/elopement. The resident's insistence in going to a psychiatric unit was not identified as wandering risk. A review of the Initial Psychiatric Evaluation dated 9/21/16, indicated Resident 1 was delusional (beliefs or impressions that are contradicted by reality), was easily irritated, had poor impulse control, heard voices telling her she would be killed, and was paranoid of being harmed. Resident 1 indicated the medications somewhat helped but she wanted to be sent to a psychiatric hospital to increase the dosage. The resident's repeated requests to go to another healthcare setting were not identified as wandering/elopement warning. There was no plan of care developed addressing the resident's risk of wandering/elopement. The Minimum Data Set (MDS - an standardized assessment and care planning tool) dated as completed on 10/15/16, indicated Resident 1 was alert and able to make herself understood, and needed supervision with walking, transfers, locomotion, and personal hygiene. The resident was assessed as having no delusions, no hallucinations, no behavioral symptoms including wandering in contradiction with the documentation by the psychiatrist findings during the initial evaluation on 9/21/16 and the documentation by social services on 9/19/16. According to a licensed nursing note dated 11/4/16, timed at 3:30 p.m., the licensed vocational nurse (LVN) received a call from Family Member 1 (FM 1) concerned about Resident 1 requesting FM 1 to take her out of the facility and wanting to know why the resident wanted to leave. The licensed nurse indicated she would find out. The licensed nurse informed the Registered Nurse (RN) supervisor and both went to check on Resident 1 and noted no unusual behavior. However, the nursing note did not indicate if Resident 1 was asked if she was planning to leave, where she wanted to go, and the reason for leaving. There was no documented evidence they (the LVN and the RN supervisor) re-assessed the resident for wandering/elopement risk due to the resident's verbalization of wanting to leave the facility. There was no documentation they listened to Resident 1's concerns, encouraged her to participate in activities, or re-directed her attention, as indicated in the plan of care. There was no plan of care developed addressing the resident's desire to leave and the Wandering Assessment form was no updated to reflect Resident 1's wandering/elopement risk. According to a licensed nursing note dated 11/10/16 and timed at 4:40 p.m., Resident 1 became anxious, agitated, was shouting at staff, and was asking for the medication Ativan for her anxiety (feeling of worry, nervousness, or unease). The physician was contacted, who ordered Ativan as needed for anxiety. A review of the plan of care dated 11/10/16, developed for Resident 1's anxiety (disorder characterized by a state of excessive uneasiness and apprehension). The goal was for Resident 1 to have no episodes of anxiety and remain relaxed and cooperative. The care plan approaches included encouraging the resident to verbalize feelings and needs, determining the reason for the anxiety, and providing attention to the resident. A review of the follow-up Psychiatric Evaluation dated 11/14/16 indicated Resident 1 complained of increased anxiety/worrying about everything and hearing voices (auditory hallucinations). The plan indicated in the evaluation was to monitor the resident and continue current medication regimen. According to the nursing note dated 11/17/16, timed at 11:45 p.m., LVN 1 noted Resident 1 was missing and staff was unable to find her. On 11/18/16, at 12:30 a.m., FM 1 was notified and at 12:45 a.m., the police department was informed of the missing person. At 6:45 a.m., seven hours after Resident 1 was noted missing, a police officer (Officer 1) called the facility informing Resident 1 was found on a street and was transported to GACH 1. On 11/23/16, at 7:10 a.m., during an interview, RN 1 stated LVN 1 informed her Resident 1 was not in her room on 11/18/16 at 11:45 p.m., a Code Green (code for missing resident) was called and a search was initiated. RN 1 stated she received a call from Officer 1 who stated Resident 1 was found lying on the sidewalk approximately two to three blocks away from the facility and was "cold and tired." RN 1 was unable to explain how Resident 1 left the facility undetected. According to the National Weather Service, the average low temperature on the night of 11/17-11/18/16 was 47 -53 degrees Fahrenheit (øF). On 12/9/16, at 7:40 a.m., during an interview, RN 2 stated she observed Resident 1 walking without assistance around the hallways. RN 2 stated if a resident verbalized wanting to leave or wanting to go home, an elopement assessment should be done right away. The resident should be evaluated for the need of a Wander Guard wristband (a signaling device to prevent elopement. When the resident goes through alarmed exit doors, the wristband will activate the alarm). RN 2 further stated a plan of care should have been developed as the resident becomes at risk for elopement. On 12/9/16, at 8:25 a.m., during an interview, the administrator stated Resident 1 spoke to her and verbalized wanting to go home or go to a psychiatric unit. According to the Fire Department emergency medical services report form, dated 11/18/16, paramedics arrived to the scene at 6:24 a.m., and found Resident 1 lying on the ground of the sidewalk, shivering, wheezing (breathing with a whistling or rattling sound in the chest, as a result of obstruction in the air passages), and with shortness of breath. The resident was transferred to GACH 1 arriving at 6:42 a.m. for further evaluation. A review of the GACH's emergency department admission notes dated XXXXXXX indicated Resident 1 was found about two blocks away from the facility complaining of feeling extremely cold, was shivering, and had pain all over. Resident 1 was found to be hypothermic with a body temperature of 96.8 øF (normal body temperature 97.7 to 99.5 øF), a high blood pressure of 201/83 mmHg (millimeters of mercury) (normal blood pressure 120/80 mmHg), a heart rate of 108 beats per minute (normal heart rate 60 to 100 beats per minute), low oxygen saturation (amount of oxygen in the blood) of 89 percent (%) (normal oxygen saturation 95 to 100%) and an increased respiration rate of 22 breaths per minute (normal respiration rate 12 to 20 breaths per minute), and had altered level of consciousness (measurement of a person's responsiveness to stimuli from the environment). Resident 1 was given intravenous (into the vein) fluids for hydration, intravenous medications to treat shortness of breath and pain, and was placed in a Bair Hugger (temperature management system uses forced, warm air to prevent and treat hypothermia). A chest X-ray taken on the same day indicated Resident 1 had pneumonitis (inflammation of the walls of the tiny air sacs in the lungs). Resident 1 was started on antibiotic therapy of Levaquin (a medication used to treat infections) 500 milligrams (mg)/100 milliliters (ml) intravenously (IV). Resident 1 remained at GACH 1 for 12 days and was discharged on XXXXXXX to a lower level care facility. The facility's undated policy and procedure titled, "Resident Supervision," indicated the objective was to provide individualized resident supervision based on a nursing assessment and resident needs. The policy was to assess and determine the level of supervision necessary to meet resident's needs and prevent any avoidable incidents. If the resident is in need of close supervision or monitoring due to multiple risk factors that can affect resident's safety, a plan of care will be initiated to address and meet the resident's need, including but not limited to frequent monitoring of resident. The facility's undated policy and procedure titled, "Elopement" did not address prevention of elopement but reporting and investigating incidents of elopement. The facility lacked policies and procedure to prevent elopement or wandering off premises. There was no policy and procedure for the Assessment for Wandering to indicate how often this form needed to be completed and the procedures the form referred to for wandering precautions and the use of a wander guard bracelet. 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 to prevent accidents and injuries, including: 1. Failure to ensure Resident 1, who verbalized in multiple occasions she wanted to go to another healthcare setting or go home, was re-assessed for wandering and elopement risk (wandering is moving about without a definite destination or purpose, wandering can be dangerous when the person goes in areas with unsafe conditions such as heavy traffic, crime, and extreme climates. The most dangerous form of wandering is elopement in which the confused person leaves an area and does not return). 2. Failure to develop a comprehensive plan of care for wandering/elopement risk with interventions including supervision and monitoring device to ensure Resident 1?s safety and prevent Resident 1 from leaving the facility without staff knowledge. 3. Failure to implement Resident 1?s plan of care intervention including re-directing attention, encouraging activity attendance, and listening to concerns to attempt reassurance and divert the resident?s attention. 4. Failure to develop comprehensive policies and procedures for wandering and elopement prevention including the use of a signaling device to alert staff when resident attempt to leave the facility and updating the wandering assessment form. As a result, on the night of 11/17/16, Resident 1 eloped from the facility; the police found her the next day in the early morning lying on a sidewalk complaining of being cold. Resident 1 was transported to GACH 1 where she was diagnosed with hypothermia (abnormally low body temperature), shortness of breath, and exacerbation (worsening) of chronic obstructive pulmonary disease (COPD - a chronic lung disease which makes it hard to breathe). The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result and was a direct proximate cause of death of Resident 1. |
| 940000014 |
Rose Villa Healthcare Center |
940008813 |
B |
19-Jan-12 |
JXI811 |
27854 |
F441 483.65(a) Infection Control Program The facility must establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection. The facility must establish an infection control program under which it investigates, controls, and prevents infections in the facility; decides what procedures, such as isolation should be applied to an individual resident; and maintains a record of incidents and corrective actions related to infections. F309 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. On October 11, 2011, at 1:10 p.m., an unannounced visit was made to the facility to conduct an annual re-certification survey. Based on observation, interview, and record review, the facility failed to follow physician?s orders and failed to implement its infection control program, under which it investigates, controls, and prevents infection for Resident 8 by not:1. Following the plan of care for incontinence and recurrent urinary tract infection to monitor the resident during urination intermittent catheterization (I/C) as stipulated per the physician's order. 2. Stocking or having readily available the necessary supplies for the resident to use sterile technique to perform the intermittent catheterization as per the physician's orders and the facility's policy and procedure.3. Teaching, reinforcing, reevaluating, and monitoring the resident's continued ability to perform I/C to prevent recurrent urinary tract infections after many urinary tract infections.As a result of these failures to follow physician?s orders resulted in Resident 8 not performing self- catheterization properly with a sterile technique and contracted five urinary tract infections (UTIs) within the past 12 months, consisting of the organisms, Escherichia coli ([E. coli] a Gram-negative, rod-shaped bacterium), Methicillin-resistant Staphylococcus aureus (MRSA/infection is caused by a strain of staph bacteria that becomes resistant to the antibiotics commonly used to treat ordinary staph infections), and Proteus Mirabilis (part of the Enterobacteriaceae family of gram-negative bacilli) over a 12 month period. These recurrent UTIs, with multiple use of antibiotics, put the resident at risk for pyelonephritis (a specific type of urinary tract infection that generally begins in the urethra or bladder and travels up into the kidneys, which requires prompt medical attention) which can lead to chronic kidney disease (CKD/a progressive loss in kidney function over a period of months or years) and failure, urosepsis (a sepsis that complicates a urinary tract or prostate infection and requires treatment with antibiotics), and the multiple use of antibiotics put the resident at risk for other antibiotic resistant infections. The resident received six different types of antibiotics for the UTIs and developed resistance to one of them after receiving that particular antibiotic many times. According to the Centers for Disease Control and Prevention (CDC), antibiotic resistance is the ability of bacteria or other microbes to resist the effects of an antibiotic that reduces or eliminates the effectiveness of drugs, chemicals, or other agents designed to cure or prevent infections. Bacteria survive and continue to multiply causing more harm.According to an article, titled the Prognosis and Management of the Neurogenic Bladder, for the significance of UTI in SCI (spinal cord injury) indicated the overall rate of UTI in SCI patients is about 1.82-2.5 episodes per patient per year. On October 12, 2011, at 1:30 p.m., during a Quality of Life group meeting, Resident 8, who self-catheterizes every four hours, stated he was upset and frustrated, because approximately a couple of weeks ago, he had been without urinary catheters for two days. As a result, the resident stated he was in pain and did not drink water for two days so that he would not have to urinate. When asked if he had spoken to anyone regarding the lack of catheters the resident stated that he had talked to the administrator and the director of nursing (DON). The ombudsman, who was present during the group meeting, stated she was aware the resident had been without urinary catheters last year, because the resident had filed a complaint with the ombudsman's office. She stated she had spoken to the facility about the issue and thought it had been resolved and was unaware that it was a continuing problem. On October 13, 2011, at 12 p.m., during an observation, in the presence of Licensed Nurse 4 (LVN), the resident was observed self-catheterizing. The resident put on gloves without washing his hands then proceeded to lubricate the catheter. The resident did not at any time clean the penis prior to catheterizing. When the resident was asked if it was a normal procedure for him to not wash his hands and to not clean the penis, the resident stated, ?I do not have the proper cleaning supplies at my bedside.? He stated every time he needed to urinate he would have to call or look for the nurses to give him supplies. The resident further stated he was frustrated with having to request for supplies every time he had to urinate, he felt he should have supplies at his bedside for emergencies. The resident stated sometimes he would feel pain from the need to urinate and that he could not always wait until he received the supplies. When the resident was asked what he used to clean the penis prior to catheterizing he stated,? Alcohol wipes.? On October 12, 2011, a review of Resident 8's Admission Record indicated the resident was a 55 year-old male admitted to the facility on June 1, 2003. The resident's diagnoses included paraplegia (paralysis of the lower part of the body, commonly affecting both legs and often internal organs below the waist), neurogenic bladder (malfunctioning bladder due to neurologic dysfunction, trauma, disease, or injury which causes difficulty or inability to pass urine without catheterization), and urinary tract infection ([UTI] a bacterial infection that affects any part of the urinary tract). A Minimum Data Set (MDS), a standardized assessment and care screening tool, dated July 13, 2011, indicated the resident was Spanish speaking and required an interpreter to communicate with a doctor or health care staff. The MDS indicated the resident was able to make himself understood and able to understand others. According to the MDS, the resident had no signs or symptoms of delirium nor did he exhibit any behavior symptoms or rejection of care. The MDS indicated the resident required intermittent catheterization. A review of the Care Assessment Area (CAA) Worksheet (triggers used to identify plan of care issues), dated July 7, 2011, indicated Resident 8 required one-person extensive assist with activities of daily living (ADL) such as bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The CAA also indicated the resident had orders to catheterize self every four hours as needed for urinary retention, ?observing clean technique? [sic], which contradicts the facility's policy. According to the CAA, the staff was to provide proper supplies for intermittent catheterization and ensure observance of good catheterization, good handwashing technique, before and after the procedure, and to monitor for bleeding as well as urine output, which the facility's staff failed to implement. A review of the facility's undated policy titled, "General Catheter Care" indicated catheters will be inserted using strict aseptic technique and sterile supplies. Hand washing will be completed immediately prior to and after any manipulation of the catheter site and or equipment. According to Encyclopedia of Nursing and Allied Health, an article titled, "Catheterization Male" indicated the nurse usually teaches the patient and or caregiver to use aseptic technique for catheter care. Nursing interventions and patient education can make a difference in the incidence of urinary tract infections in the hospital, nursing homes, and home care units.A review of a care plan titled, "Incontinence" dated May 9, 2011 and revised July 13, 2011, indicated the staff should monitor the resident's urine output and bleeding. However, on October 13, 2011, at 2:20 p.m., Licensed Vocational Nurse 1 was asked if the facility had ever observed a return demonstration of the resident self catheterizing. The LVN stated that if it had been done the documentation could be found on the resident's intake and output form. When asked if she had ever observed the resident self catheterizing LVN 1 stated, "No, he was independent. We do not watch him catheterize.? However, a physician?s order dated May 14, 2007, indicated the resident to catheterize self every four hours or as needed for urinary retention and the staff to monitor urination and output for bleeding at each episode of catheterization. A review of another care plan titled, "Urinary Tract Infection-Recurrent " dated May 9, 2007, and revised July 13, 2011, indicated the nursing staff should assess the resident for incontinence, presence of cloudy, and/or foul smelling urine. A review of Medication Administration Records (MARs), dated for the months of May 2011 through October 2011, indicated a physician's order written on July 3, 2007, for the staff were to monitor the resident's urination and call the medical doctor (MD) if problem occurs.A review of physicians? orders, licensed nurses? notes, MARs, and laboratory reports for the months of September 2010 through September 2011, indicated the resident was treated for urinary tract infections (UTI) with the following antibiotics: 1. On September 2010 ( MAR) Doxycycline (anti-infective) 100 milligram (mg) one tab to be administered to the resident by mouth two times a day for 10 days. 2. On September 7, 2010, the resident was seen at a general acute care hospital (GACH) after complaining of pus from the penis. A urine culture/sensitivity was done and was positive for 100,000 CFU/ml Escherichia coli and was started on Macrobid 100 mg. twice a day for UTI. 3. September 11, 2010, the physician?s note indicated the resident had another UTI and (Physician?s note) was seen by an urologist at a GACH with a positive C/S for E. coli and was treated with Macrobid. The note indicated the resident?s blood urea nitrogen (BUN) and creatitinine was elevated at 30 and 2.0 (normal reference range 10-20 mg/dl and .6-1.2 mg/dl). The Physiciain wrote ?CKD [chronic kidney failure] secondary to recurrent UTI.?4. October 2010 (MAR) Doxycycline 100 mg one capsule by mouth two times per day for 10 days for a boil (infection of the hair follicle, most commonly caused by infection by the bacterium Staphylococcus aureus) in pubic area. 5. April 4, 2011 (physicians? order), Ciprofloxacin ([Cipro] an anti-infective) 250 mg tab to be given by mouth two times a day for 10 days for testicular variocele (an enlargement of the veins within the scrotum).6. April 19, 2011, according to a nurses? note, the resident had an elevated body temperature of 101.3-101.8 Fahrenheit (F) (average normal body temperature is 98.6 F) and complained of right abdominal/groin pain (6/10). The resident was sent to the GACH via ambulance. The physician ordered Cipro.500 mg. twice a day for 10 days. 7. May 18, 2011, Resident 8 was complaining of stomach pain and had a discharge (Nurses? Note) of pus (a whitish-yellow, yellow, or yellow-brown exudate formed at the site of inflammation, during an infection) from the penis. 8. May 23, 2011 (physician?s order), Doxycycline 100 mg to be administered to the resident by mouth two times per day for 10 days for penile MRSA infection and contact isolation. The resident stayed in contact isolation from May 23, 2011 until June 28, 2011. 9. A review of a laboratory report, dated May 23, 2011, indicated Resident 8's penis culture was positive for Methicillin/oxacillin resistant. Organism 1: light growth Escherichia coli. Organism 2: light growth Staphylococcus Aureus. Written on the report was "Doxycycline 100 mg. Bid X 10 days." However, a further review of the culture and sensitivity (C/S/ a culture is done to identify what kind of organism [usually bacteria] and the sensitivity checks to see what kind of medicine would best treat the infection) indicated Doxycycline was not listed as one of the drugs the organism was sensitive to. 10. June 10, 2011, a laboratory report indicated the penis discharge culture had moderate growth of Proteus mirabilis (family of gram-negative bacilli). 11. June 13, 2011 (physician?s order), Keflex (an anti-infective used to treat urinary tract infections) 500 mg to be administered to the resident by mouth three times per day for penile discharge. The resident complained of nausea and vomiting and Keflex was discontinued. 12. June 13, 2011 (physician?s order), Bactrim DS [double strength] (Sulfamethoxazole-Trimethoprim) 800-160 mg to be administered to the resident by mouth three times per day for 10 days for the penile discharge. A review of the same physician's order indicated the resident was allergic to sulfa drugs, Trimethoprim.Bactrim was discontinued on June 14, 2011. 13. June 14, 2011 (physician?s order), Keflex 250 mg to be administered to the resident by mouth with meals three times a day for 10 days for penile discharge infection. The resident was complaining of nausea and vomiting after receiving Keflex. Keflex was discontinued on June 15, 2011 after an episode of vomiting. 14. June 22, 2011, According to a nurses? note dated June 15, 2011, the physician called and order for the resident to be seen at the GACH?s urologist clinic on June 22, 2011 for the penile discharge. 15. June 28, 2011, the urologist report, dated June 28, 2011, indicated the resident had a urine C/S done and to start the resident on Bactrim twice a day for 10 days. 16. July 3, 2011, An internal medicine note indicated the residents? penile discharge was better, but had ?GI upset due to antibiotics.? Penile culture- proteus mirabilis and a repeated C/S was done at a urology clinic, awaiting results. The note indicated ?urethritis, resolving.?17. July 2011(MAR) Bactrim DS (Sulfamethoxazole-Trimethoprim) one tab to be administered to the resident by mouth twice a day for 10 days. The order was discontinued on July 8, 2011, after an initial dose was given although it was written on the MAR the resident was allergic to sulfa drugs. 18. July 2011 (MAR) Ciprofloxacin 500 mg to be administered to the resident one tab by mouth twice a day for 7 days for UTI. The order was discontinued on July 11, 2011. A Licensed Nurses Progress Note, dated July 11, 2011, timed at 10 a.m., indicated the facility received the resident's old laboratory results on July 7, 2011 from a culture and sensitivity, dated June 22, 2011. According to the note, the physician ordered Bactrim DS for UTI based on the old laboratory report. However, this was the second time the resident had an order to receive Bactrim DS,(double strength) as indicated in the clinical records, although the resident was allergic to Bactrim. The resident was given one dose of Bactrim, on July 8, 2011. The order was changed to Cipro and on July 11, 2011, the physician discontinued Cipro, after the resident received the antibiotic for four days. 19. August 2011 (MAR) Ciprofloxacin 250 mg to be given to the resident by mouth two times a day for 10 days to treat phlegm and UTI. The physician's order was dated August 24, 2011, but was discontinued on August 26, 2011.20. August 25, 2011, a laboratory report indicated the resident's urine culture had more than 100,000 colonies/ml of Escherichia coli. The report also indicated the organism was resistant to Ciprofloxacin, Levofloxacin, and Tobramycin. 21. August 2011 (MAR), Macrobid (an anti-infective used to treat UTI) 100 mg to be administered to the resident by mouth two times per day for 10 days for the diagnosis of UTI. The physician's order was dated August 26, 2011, and Macrobid was discontinued three days later, (August 29, 2011). 22. August 2011 (MAR), Keflex 250 mg was ordered to be administered to the resident by mouth three times a day for 10 days for UTI, although in June 2011, the resident had nausea and vomiting after receiving this antibiotic. On August 29, 2011, Keflex was discontinued due to the resident having nausea and vomiting. 23. August 29, 2011, Rocephin 1 gram (GM) intravenous [into the vein] (IV) ordered to be given every day for seven days, which was started on August 30, 2011 and completed on September 5, 2011. On October 13, 2011, at 12 p.m., in an interview, the resident was asked if any of the nurses ever observe him while he catheterizes himself. The resident stated, ?No, I catheterize and after I?m done. I call the nurses so they can throw away the urine.? There was no documentation to support the staff implemented the physician?s order to monitor the resident during I/C. In an interview, on October 13, 2011, at 2:25 p.m., LVN 2 was asked if Resident 8 had ever been assessed for self- catheterization. The LVN stated the issue had been discussed in the Interdisciplinary meeting however, she was not aware of any teaching that had been done. On October 13, 2011, at 2:30 p.m., in an interview, the director of nursing (DON) stated the resident has had re-current UTIs and he had not been re-assessed in regards to self-catheterization. The DON stated the facility needed to re-educate the resident. When asked if she could find any documentation indicating the resident had been educated in the facility on how to self-catheterize the DON stated she could not. On October 14, 2011, at 7:10 a.m., one Foley insertion tray was observed at the resident's bedside. The tray included Povidine iodine ([PVP] used for the prevention and treatment of skin infections, and the treatment of wounds) swab sticks, a 30 milliliter syringe pre-filled with sterile water, vinyl gloves, lubricating jelly, one underpad, one drape, and a tray. An interview with the resident, while at the bedside, the resident stated the kit had been given to him the night before (on October 13, 2011) by the DON. The resident stated it was to be used for his next catheterization, but that the kit was only good for one use. The resident stated this was the first time he had received a kit, because the staff would just give him individual alcohol wipes. He stated the only time he had been taught how to self-catheterize prior to the survey, had been at the GACH prior to his admission to the skilled nursing facility (SNF) in 2003. LVN 2 confirmed the residents? statement when she was questioned about the resident receiving any I/C teaching and she replied, ?I am not aware of any I/C teaching being done.? When the resident was asked about the time he was without catheters for two days the resident stated the facility had offered him a different type of catheter, but neither he nor a licensed nurse had been able to use the catheter because it would bend making it difficult for insertion. The resident stated after two days, when he was finally able to catheterize, his urine smelled very bad. When asked if he had experienced pain after waiting two days to catheterize the resident stated, "Yes." When asked if he could rate the pain on a scale of one to ten, ten being very intense pain, the resident stated his pain level was at five. During an interview, the director of social services stated recently the facility had changed vendors. As a result, Resident 8 had complained the new catheters were too "Flimsy." She stated she had to go to other sister facilities to obtain catheters for the resident.On October 14, 2011, at 7:15 a.m., in an interview, the DON was asked if she was aware the resident had been without catheters before, for two days. The DON stated the facility had changed vendors and the resident did not like the catheters from the new vendor. When asked when the facility had changed vendors the DON stated, "It was around August 2011." The DON was asked what the process was to ensure the resident had enough supplies. The DON stated during the evening shift (3 p.m. to 11 p.m.) the resident would ask for supplies. At that time, the resident would be provided with six catheters, however he was not always given a kit (Foley Insertion Tray). The DON stated the resident was required to ask the nurses for the supplies he needed to catheterize. When asked what supplies are given to the resident the DON replied, "Alcohol wipes and lubricant." The DON also stated the facility does not carry the single PVP swabs that are found in the kit. On October 14, 2011, at 8 a.m., an observation of the facility's supply room was made in the presence of Certified Nurse Assistant 1 (CNA) who stated she was also responsible for ordering supplies. Among the supplies observed were six size 14 French (F) catheters, the size Resident 8 used, and one Foley Insertion Tray. During the observation, CNA 1 stated she orders five Foley Insertion Trays per week. She also stated she was not aware Resident 8, used the kits, only that she was told by the LVN to order five per week. In an interview, on October 14, 2011, at 8:05 a.m., LVN 3 stated the facility's two treatment carts (which are stocked with supplies used for various treatments) did not contain any Foley Insertion Trays or catheters. On October 14, 2011, at 8:07 a.m., in an interview Resident 8 stated he had one catheterization kit for the day, which he was getting ready to use. The resident was asked how it felt to use alcohol wipes on his penis, he stated, "It stings." The resident also asked if it was possible for the survey team to speak to the staff about giving him supplies. He stated it was hard for him to always have to look for staff every time he needed to urinate. In addition, the resident expressed fear and concern that as a result of speaking to the survey team about his problems he had been experiencing in the facility. The facility would in turn have him examined by a psychiatrist to make it look like he was crazy. On October 14, 2011, at 10:45 a.m., the clinical resource specialist (corporate consultant) was asked if it was appropriate to use alcohol wipes to clean the penis prior to catheterization. She stated using alcohol wipes on the penis was not the standard of practice. During a telephone interview, on October 14, 2011, at 12:40 p.m., Resident 8's attending physician stated the facility had called her the night before (Thursday, October 13, 2011) after the survey team expressed concerns about the resident's lack of training and supplies for catheterization. She stated the facility informed her the resident was non-compliant. The physician stated she asked them if they had documented and care planned the resident's non-compliance. The physician stated, "The head nurse should get the nurses to do what they are supposed to do." She also stated a few years back she had discussed the proper technique for self-catheterization with the resident and that he had not followed sterile technique. When asked if she had or seen any documentation of the resident not being compliant, she stated, ?No, not recently. "The physician stated, "I've told the nurses he needs to be watched and monitored. They are supposed to watch him." The physician stated she had verbally re-iterated to the nurses last year, the importance of monitoring the resident. She further stated she should not have to write an order for the nurses to monitor the resident during the catheterization procedure because, "Nurses should know what they are supposed to do." She also stated the resident needed to be monitored on a regular basis and that was why she wrote and told the nurses to monitor him. When asked if she was aware the facility was giving the resident alcohol preps to clean his penis prior to the procedure, she stated "No." In an interview, on October 14, 2011, at 1:20 p.m., the facility's medical director stated self-catheterization was a sterile procedure and the urinary meatus (the point at which, in males, the urine and semen exits the urethra) should be cleaned with Betadine, if not there is a high chance of contracting a UTI. The medical director also stated intermittent catheterization was less likely to cause a UTI as opposed to an indwelling catheter. According to Medline Plus Medical Encyclopedia, infections occur less often in males and using intermittent catheterization compared to the use of an indwelling catheter. When the medical director was asked if it was acceptable to use alcohol around the urinary meatus the director stated, "No, it will burn." The director was asked what he would do for a resident who was self-catheterizing and having re-current UTIs. The director stated it was important to re-educate individuals who are self-catheterizing in order to make sure they are doing the procedure correctly.On October 14, 2011, at 3 p.m., the resident was asked how he would feel if the facility assisted him with self-catheterization. The resident stated, "I would appreciate the help, because it is difficult to position myself due to being paralyzed and gathering the necessary supplies for the procedure." In an interview on October 17, 2011, at 8 a.m., CNA 2 stated Resident 8 was very pleasant and easy to work with. She also stated she had never witnessed him being combative. When asked if she had ever witnessed the resident catheterizing himself, she stated, "No." On October 18, 2011, at 8 a.m., CNA 1, who was responsible for patient care, as well as ordering the facility's supplies, stated the supplies were ordered once a week, no later than 1 p.m. She stated the charge nurse or DON were responsible for letting her know what to order. However, she stated sometimes things are missed and when that happens, it can take days to receive the supplies. According to the physician's order, the resident was to self-catheterize every four hours, as needed (PRN), which would require the resident to use 42 catheters per week. A review of the facility's form titled, Purchase Orders, dated July, 2011 through September 2011, indicated the number of 14Fr catheters ordered for the facility were as follows: July 12, 2011= 12 July 19, 2011=36 July 26, 2011=36 August 2, 2011=24 August 11, 2011=36 August 16, 2011=24 August 23, 2011=36 September 6, 2011=36All of the above orders were less than the 42 catheters per week Resident 8 required to catheterize himself at least every four hours, per the physician?s order.The facility failed by not: 1.Following the plan of care for incontinence and recurrent urinary tract infection to monitor the resident during urination intermittent catheterization (I/C) as stipulated per the physician's order. 2. Stocking or having readily available the necessary supplies for the resident to use sterile technique to perform the intermittent catheterization as per the physician's orders and the facility's policy and procedure.3. Teaching, reinforcing, reevaluating, and monitoring the resident's continued ability to perform I/C to prevent recurrent urinary tract infections after many urinary tract infections. These violations, either jointly, separately, or in combination, had a direct relationship to the health, safety, or security to Resident 8. |
| 940000014 |
Rose Villa Healthcare Center |
940008814 |
B |
19-Jan-12 |
JXI811 |
15783 |
F 224483.13(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 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. Based on observation, interview, and record review, the facility's staff failed to ensure Resident 8, who was a paraplegic (paralysis of the lower part of the body, commonly affecting both legs and often internal organs below the waist), and was dependent upon staff for much care was free from neglect by: 1. Failing to provide training, monitoring, assessment, and re-evaluation of the resident's ability to perform intermittent catheterization (I/C) to prevent urinary tract infections. 2. Failing to stock or have readily available the necessary supplies for Resident 8 to perform sterile technique intermittent self-catheterization as per the facility's policy and procedure. These failures resulted in Resident 8 feeling upset, frustrated, and also fearful, after speaking to the survey team about the facility's lack of supplies for him to perform I/C. Resident 8 contracted many urinary tract infections (UTIs), consisting of the organisms, Escherichia coli ([E. coli] a Gram-negative, rod-shaped bacterium), Methicillin-resistant Staphylococcus aureus (MRSA/ infection is caused by a strain of staph bacteria that becomes resistant to the antibiotics commonly used to treat ordinary staph infections), and Proteus Mirabius (part of the Enterobacteriaceae family of gram-negative bacilli) over a 12 month period. The resident received five different types of antibiotics for the UTIs and developed resistance to one of them (Cipro) after receiving that particular antibiotic many times.On October 12, 2011 at 1:30 p.m., during a Quality of Life group meeting, Resident 8, who self-catheterizes every four hours, stated he was upset and frustrated, because approximately a couple of weeks ago, he had been without urinary catheters for two days. As a result, the resident stated he was in pain and did not drink water for two days so that he would not have to urinate. When asked if he had spoken to anyone regarding the lack of catheters the resident stated that he had spoken to the administrator and the director of nursing (DON). The ombudsman (patient advocate, who investigates complaints), who was present during the group meeting, stated she was aware the resident had been without urinary catheters last year, because the resident had filed a complaint with the ombudsman's office. She stated she had spoken to the facility about the catheter issue and thought it had been resolved and was unaware that it was a continuing problem. On October 12, 2011, a review of the resident's Admission Face sheet indicated the resident was a 55 year-old male admitted to the facility on June 1, 2003. The resident's diagnoses included paraplegia, neurogenic bladder (malfunctioning bladder due to neurologic dysfunction, trauma, disease, or injury which causes difficulty or inability to pass urine without catheterization), which required daily intermittent catheterization ([I/C] a narrow, plastic tube, called a catheter, is placed into the urethra each time a person needs to empty their bladder) every four hours to relieve the bladder of urine and urinary tract infection ([UTI] a bacterial infection that affects any part of the urinary tract). On October 13, 2011, at 12 p.m., during an observation, in the presence of Licensed Nurse 4 (LVN), the resident was observed self-catheterizing. The resident put on gloves without washing his hands then proceeded to lubricate the catheter. The resident did not clean the penis prior to catheterizing. When the resident was asked if it was a normal procedure for him to not wash his hands and to not clean the penis the resident stated, "I do not have the proper cleaning supplies at my bedside." He stated every time he needed to void he would have to call or look for the nurses to give him supplies. The resident further stated he was frustrated at having to request for supplies every time he had to urinate, he felt he should have supplies at his bedside for emergencies. The resident stated sometimes he would feel pain from the need to urinate and could not always wait until he received the supplies. When the resident was asked what he used to clean the penis prior to catheterizing he stated, "Alcohol wipes." On October 13, 2011, a review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated July 13, 2011, indicated the resident was Spanish speaking and required an interpreter to communicate with the doctor or health care staff. The MDS indicated the resident was able to make himself understood and able to understand others. According to the MDS, the resident had no signs or symptoms of delirium nor did he exhibit any behavior symptoms or rejection of care. The MDS indicated the resident required intermittent catheterization. A physician's order dated May 14, 2007, indicated the patient was to self-catheterize every four hours or as needed for urinary retention and the staff was to monitor urine and output for any bleeding in each episode of catheterization. Another physicians' order dated July 3, 2007, read: "Monitor urination, call medical doctor if problem occurs." On October 13, 2011, at 2:20 p.m., Licensed Vocational Nurse 1 was asked if the facility had ever observed a return demonstration of the resident self-catheterizing. The LVN stated that she had never observed the resident self-catheterizing and stated, "The resident was independent. We do not watch him catheterize. " In an interview, on October 13, 2011, at 2:25 p.m., LVN 2 was asked if Resident 8 had ever been assessed for self-catheterization. The LVN stated the issue had been discussed in the Interdisciplinary meeting; however, she was not aware of any teaching that had been done. On October 13, 2011, at 2:30 p.m., in an interview, the director of nursing (DON) stated the resident had recurrent UTIs and he had not been re-assessed about self-catheterization. The DON stated the facility needed to re-educate the resident. When asked if she could find any documentation indicating the resident had been educated in the facility on how to self-catheterize the DON replied, she could not. A review of the facility's undated policy titled, "General Catheter Care" indicated catheters will be inserted using strict aseptic technique and sterile supplies. Hand washing will be completed immediately prior to and after any manipulation of the catheter site and or equipment. On October 14, 2011, at 7:10 a.m., one Foley insertion tray was observed at the resident's bedside. The tray included Povidine iodine ([PVP] used for the prevention and treatment of skin infections, and the treatment of wounds) swab sticks, a 30 milliliter syringe pre-filled with sterile water, vinyl gloves, lubricating jelly, one under pad, one drape, and a tray. In an interview with the resident, while at the bedside, the resident stated the kit had been given to him the night before (on October 13, 2011, after the survey team had made inquiries) by the DON. The resident stated it was to be used for his next catheterization, but that the kit was only good for one use. The resident stated this was the first time he had received a kit, because the staff usually gave him individual alcohol wipes. He stated the only time he had been taught how to self-catheterize prior to the survey, had been at the general acute care hospital (GACH) prior to his admission to the skilled nursing facility (SNF) in 2003. LVN 2 confirmed the residents' statement when she was questioned about the resident receiving any I/C teaching and she replied, "I am not aware of any I/C teaching being done." When the resident was asked about the time he was without catheters for two days the resident stated the facility had offered him a different type of catheter, but neither he nor a licensed nurse had been able to use the catheter because it would bend making it difficult for insertion. The resident stated after two days, when he was finally able to catheterize, his urine smelled very bad. When asked if he had experienced pain after waiting two days to catheterize the resident stated, "Yes." When asked if he could rate the pain on a scale of one to ten, ten being very intense pain, the resident stated his pain level was at five. During an interview, the director of social services stated recently the facility had changed vendors. As a result, Resident 8 complained the new catheters were too "Flimsy." She stated she had to go to other sister facilities to obtain catheters for the resident. On October 14, 2011, at 7:15 a.m., in an interview, the DON was asked if she was aware the resident had been without catheters before for two days. The DON stated the facility had changed vendors and the resident did not like the catheters from the new vendor. When asked when the facility had changed vendors the DON stated, "It was around August 2011." The DON was asked what the process was to ensure the resident had enough supplies. The DON stated during the evening shift (3 p.m. to 11 p.m.) the resident would ask for supplies. At that time, the resident would be provided with six catheters; however he was not always given a kit (Foley Insertion Tray). The DON stated the resident was required to ask the nurses for the supplies he needed to catheterize. When asked what supplies are given to the resident the DON replied, "Alcohol wipes and lubricant." The DON also stated the facility does not carry the single PVP swabs that are found in the kit. On October 14, 2011, at 8 a.m., an observation of the facility's supply room was made in the presence of Certified Nurse Assistant 1 (CNA) who stated she was also responsible for ordering the facility's supplies. Among the supplies observed were six size 14 French (F) catheters, the size Resident 8 used, and one Foley Insertion Tray. During the observation, CNA 1 stated she orders five Foley Insertion Trays per week. She also stated she was not aware Resident 8, used the kits, only that she was told by the LVN to order five per week. In an interview, on October 14, 2011, at 8:05 a.m., LVN 3 stated the facility has two treatment carts, which are stocked with supplies used for various treatments. However, upon observation the carts did not contain any Foley Insertion Trays or catheters. On October 14, 2011, at 8:07 a.m., in an interview Resident 8 stated he had the one catheterization kit for the day, which he was preparing to use. The resident was asked how it felt to use alcohol wipes on his penis, he stated "It stings." The resident also asked if it was possible for the survey team to speak to the staff about giving him supplies. He stated it was hard for him to always have to look for staff every time he needed to urinate. In addition, the resident expressed fear and concern, as a result of speaking to the survey team, that the facility would in turn have him examined by a psychiatrist to make it look like he was crazy. On October 14, 2011, at 11:12 a.m., in an interview, the supervisor ombudsman stated the resident had filed a complaint last year (February 2010) indicating the facility had not provided him with catheters. However, she stated she thought the issue had been resolved because her worker had spoken to the facility and was told the catheters had been acquired from a sister facility. During a telephone interview, on October 14, 2011, at 12:40 p.m., Resident 8's attending physician stated the facility had called her the night before (Thursday, October 13, 2011) after the survey team expressed concerns about the resident's lack of training and supplies for catheterization. The physician stated, "The head nurse should get the nurses to do what they are supposed to do." The physician stated, "I've told the nurses he needs to be watched and monitored during the catheterization procedure. They are supposed to watch him." The physician stated she had verbally re-iterated to the nurses last year of the importance of monitoring Resident 8. In an interview, on October 14, 2011, at 1:20 p.m., the facility's medical director stated self-catheterization was a sterile procedure and the urinary meatus (the point at which, in males, the urine and semen exits the urethra) should be cleaned with Betadine, if not there is a high chance of contracting a UTI. The medical director also stated intermittent catheterization was less likely to cause a UTI as opposed to an indwelling catheter. According to Medline Plus Medical Encyclopedia, infections occur less often in males and using intermittent catheterization compared to the use of an indwelling catheter. When the medical director was asked if it was acceptable to use alcohol around the urinary meatus the director stated, "No, it will burn." The director was asked what he would do for a resident who was self-catheterizing and having re-current UTIs. The director stated it was important to re-educate individuals who are self-catheterizing in order to make sure they are doing the procedure correctly.On October 14, 2011, at 3 p.m., the resident was asked how he would feel if the facility assisted him with self-catheterization. The resident stated, "I would appreciate the help, because it is difficult to position myself due to being paralyzed and gathering the necessary supplies for the procedure." In an interview on October 17, 2011, at 8 a.m., CNA 2 stated Resident 8 was very pleasant and easy to work with. She also stated she had never witnessed him being combative.On October 18, 2011, at 8 a.m., CNA 1, who was responsible for patient care, as well as ordering the facility's supplies, stated the supplies were ordered once a week, no later than 1 p.m. She stated the charge nurse or DON were responsible for letting her know what to order. However, she stated sometimes things are missed and when that happens, it can take days to receive the supplies. According to the physician's order, the resident was to self-catheterize every four hours, which would require the resident to use 42 catheters per week. A review of the facility's form titled, Purchase Orders, dated July 2011 through September 2011, indicated the number of 14Fr catheters ordered for the facility were as following: July 12, 2011= 12 July 19, 2011=36 July 26, 2011=36 August 2, 2011=24 August 11, 2011=36 August 16, 2011=24 August 23, 2011=36 September 6, 2011=36 All the above orders were less than the 42 catheters per week Resident 8 required to catheterize himself at least every four hours, per the physician's order. A review of the facility's undated policy titled, "In the Nursing Home" indicated all residents have the right to be free from "abuse and neglect." The policy indicated neglect was when the resident's needs were not met and indicated the resident should report it to the family, Ombudsman, and or State Agency. The facility failed by: 1. Failing to provide training, monitoring, assessment, and re-evaluation of the resident's ability to perform intermittent catheterization (I/C) to prevent urinary tract infections.2. Failing to stock or have readily available the necessary supplies for Resident 8 to perform sterile technique intermittent self-catheterization as per the facility's policy and procedure. This violation had a direct relationship to the health, safety, or security to Resident 8. |
| 940000023 |
REGENCY OAKS POST ACUTE CARE CENTER |
940010900 |
B |
31-Jul-14 |
5QG411 |
6615 |
F 281 Services-Meet Professional Standards ?483.20(k)(3)(i) The services provided or arranged by the facility must meet professional standards of quality and;Based on observation, interview and record review, the facility failed to ensure professional standards of quality by:1. Not Performing Neurological checks accurately (a brief assessment to check nervous system for injury or dysfunction) as ordered by a physician for Resident 3, after he sustained blunt head trauma. 2. Allowing a licensed vocational nurse (LVN) to perform neuro-checks, which was beyond her scope of practice.These failures of having a LVN work beyond her scope of practice and inaccurately perform neuro-checks had the potential for inaccurate results, which could lead to adverse consequences for Resident 3. On June 6, 2014, at 7:10 a.m., during an unannounced complaint investigation regarding another complaint, an entity reported incident (ERI) was presented related to a resident to resident altercation that occurred on June 4, 2014, between Resident 3 and another resident. Resident 3 sustained blunt head trauma. A review of Resident 3?s Admission Face Sheet indicated the resident was a 64 year-old male who was admitted to the facility on June 4, 2014. The resident?s diagnoses included hypercapnia (excessive level of carbon dioxide in the blood), chronic obstructive pulmonary disease (COPD: obstructive lung disease) and pneumonia (infection in the lungs). A review of Residents 3?s initial assessment titled ?Clinical Health Status, dated June 4, 2014 and timed at 5:30 p.m. indicated Resident 3 was awake, alert and oriented to time, place and person. A review of a telephone physician?s order, dated June 4, 2014, and timed at 7:30 p.m., indicated neuro-checks were ordered to be done every day for 72 hours on Resident 3. According to an article titled, ?Neurological Assessment? the recognition of a change in mental status can make a significant impact on a patient?s prognosis, early identification of neurological deterioration is vital to preventing secondary brain injury. www.nursing.advanceweb.com According to another article titled, ?What Are Neuro Checks? indicated the purpose of a neuro check after blunt head trauma is to compare the current level with the initial level to determine if the patient is progressing, regressing or holding his own. A neuro assessment eye examination focuses upon the pupils. The initial assessment should have noted the patient's ability to see, visual field and the reaction to light as measured by the pupils. Neuro checks follow up on the pupils' reactions to light to determine any change in condition, as well as confirming no change in the ability to see. www.modernmedicine:Neurological Assessment: A Refresher.com An interview with Resident 3 was conducted on June 6, 2014 at 2:07 p.m., Resident 3, who was alert and oriented to person, place, time and events and was able to voice concerns and he stated, ?No one had ever checked my eyes at all, during the day, evening or at night.? Resident 3 stated no one has ever checked his eyes with a flashlight nor checked his hands and feet for strength. On June 6, 2014, at 2:10 p.m., a licensed vocational nurse (LVN 1) stated in the presence of Resident 3, she accurately performed neuro-checks on Resident 3. Resident 3 turned toward LVN 1 and stated, ?No you did not; you have never checked my eyes.? LVN 1 stated she performed neuro-checks on June 5, 2014, for Resident 3 by using a flashlight application on her personal cellular telephone. After she was encouraged to be forthcoming, LVN 1 stated she performed neuro-checks on Resident 3 that morning (June 6, 2014) by drawing the resident?s curtain opened to sun-light. During an interview on June 9, 2014, at 7:38 a.m., a registered nurse (RN 1) stated, the use of a penlight or flashlights are used to perform neuro-checks. RN 1 was asked if neuro-checks can be performed without a penlight or flashlight, RN 1 stated, ?No.? A review of the facility?s licensed nurse?s schedule indicated there were two RNs on duty on the day shift (RN supervisor and the DON). On June 9, 2014 at 10:25 a.m., the director of nurses (DON) stated, ?Neuro-checks are performed every 15 minutes for 72 hours. A review of the facility?s neurological assessment sheet stipulated a neuro check every 15 minutes for one hour, every 30 minutes for 2 hours and every hour for 4 hours. On June 4, 2014, June 5, June 6 and June 7, 2014, neuro checks were performed and signed by LVN?s. On June 9, 2014, at 10:40 a.m., while at Resident 3?s bedside, LVN 1 was asked to demonstrate how she does neuro-checks in the presence of two evaluators. LVN 1 used a flashlight and performed pupillary (small black hole in the center of the eye) reaction with the residents curtain open to sunlight and overhead light on in the room. LVN 1 manually lifted both of Resident 3?s legs, while stating ?I?m checking for leg strength.? On June 24, 2014, at 1:46 p.m., during a telephone interview, the DON stated the facility?s policy stipulated that any licensed nurse can do neuro-checks, when asked who should do assessments; the DON stated ?Rns should do assessments, but the LVNs can do neuro-checks.? A review of the facility?s policy titled ?Neurological Assessment? indicated it required a physician?s order for unwitnessed falls, head trauma, injuries and or when indicated for the resident?s condition. According to Title 22 CCR Section 70215 (a) (1) ?A registered nurse (RN) shall directly provide ongoing patient assessments. An RN is accountable for an ongoing comprehensive assessment that includes data collection, analysis, and drawing conclusions/making judgments in order formulate or change the plan of care. ? According to California Correctional Health Care Services, a policy titled ?Licensed Vocational Nurse Scope of Practice Standards?, Chapter 5, dated January 2002, indicated an LVN may assist in the collection of data during the assessment process. Validation of assessment data, however, must be done by the RN. The LVN may not perform a comprehensive assessment. The facility failed by: 1. Not Performing Neurological checks accurately (a brief assessment to check nervous system for injury or dysfunction) as ordered by a physician for Resident 3, after he sustained blunt head trauma. 2. Allowing a LVN to perform neuro-checks, which was beyond her scope of practice. The above violations either jointly, separately, or in any combination had a direct or immediate relationship to patient health, safety, or security. |
| 950000007 |
Ramona Nursing & Rehabilitation Center |
940011286 |
A |
25-Mar-15 |
N3IW11 |
11195 |
F323 - 42 CFR 483.25(h) (2) Accidents The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure that Resident 1, a left leg amputee who was assessed as being at high risk for falls and needed extensive assistance from staff during toileting, received adequate supervision to prevent fall and injury. And as result, Resident 1 who was left unsupervised in the bathroom, stood up to pull his underwear, fell to the floor, and sustained an acute intertrochanteric (hip) fracture with mild displacement.A review of Resident 1's Admission Record indicated that the resident was initially admitted to the facility on 5/21/2014, and readmitted on 6/29/2014 with diagnoses that included general weakness, abnormal gait, hypertension (high blood pressure), and a left leg above knee amputation. A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/28/2014, indicated that Resident 1's cognition was intact (the brain/mind processed information in a normal way). The resident was able to make his needs known and understand others, but required extensive assistance from staff with a one person physical assist for transferring, personal hygiene, and toilet use. The resident used a walker, wheelchair, and left lower extremity prosthesis (an artificial body part, such as a leg) to get around the facility. During an observation, on 8/22/14, at 1:05 p.m., Resident 1 was lying in bed. The resident's left hip area was covered with green colored bruises. During a concurrent interview, Resident 1 stated that he fell and broke his hip. He further stated, "Oh this pain is killing me." At 8/22/14, at 1:10 p.m., during another interview, Resident 1 stated that he fell in the bathroom and it was a routine for the nurse to help him to the bathroom and leave him unsupervised. The resident stated whenever he was done using the bathroom, he would clean himself up, and push the call light for the nurse to help him out of the bathroom. The resident stated that he had done this routine many times in the past. Resident 1 stated, this time (on 8/4/14) when he stood to pull his underwear up, his body turned and he fell to the floor.On 8/22/14, at 2:10 p.m., during an interview, Certified Nursing Assistant (CNA) 1 stated that on 8/4/14, Resident 1 asked her to help him to the bathroom, so she brought the wheelchair to the resident. CNA 1 stated the resident was able to transfer himself to the wheelchair, then she pushed the resident to the bathroom. CNA 1 stated while in the bathroom, the resident transferred himself from the wheelchair to the toilet by grabbing on the two grab bars in the bathroom (on the left and right of the toilet.) CNA 1 stated she pushed the wheelchair out of the bathroom, closed the bathroom door for privacy, and left the room to help other residents. CNA 1 stated she had taken care of Resident 1 before, and was familiar with the resident's needs. CNA 1 stated whenever she helped Resident 1 to the bathroom; the resident would transfer himself from the wheelchair to the toilet, cleaned himself, pull his underwear up (fully clothed), and push the call light for her to bring the wheelchair back to the bathroom. CNA 1 stated that all she needed to do for the resident was to bring the wheelchair and push him out of the bathroom. CNA 1 stated Resident 1 liked to be independent (do things by himself); he did not like the staff to help with the tasks, and he would normally perform all the tasks by himself. CNA 1 stated the resident was wearing a non-skid sock but she did not check to see if the sock was properly placed. A review of a Fall Risk Assessment (an assessment of the resident's status in eight clinical condition parameters such as: level of consciousness, history of falls, ambulation, elimination status, vision status, gait/balance, systolic blood pressure, medications, and predisposing diseases), dated 7/4/14 and 8/4/14, indicated that Resident 1 had a score of 14. According to the assessment, a total score of 10 or above represents a high risk for falls. A review of Resident 1's nursing care plan, dated 6/29/14, indicated that the resident was at risk for fall or injury due to left leg amputation, generalized weakness, improper posture, receiving hypertension and psychoactive medications. The staffs approach interventions were to keep close observation during activities to minimize potential for fall and to have physical therapist/occupational therapist (OT/PT) evaluation done if indicated. A review of nursing care plan, dated 6/29/14, indicated that Resident 1 required assistance in transferring, dressing, toilet use, and personal hygiene due to multiple medical conditions. The staff interventions were to assist the resident with transfer, locomotion, and toileting. A review of the "Occupational Therapy Discharge Summary," dated from 7/29/14 to 8/1/14, indicated for lower body dressing, the resident needed CGA (contact guard assist) and for toileting the resident needed SBA (stand by assist). During an interview with the occupational therapist (OT), on 8/22/14, at 2:30 p.m., she stated that the resident was assessed as not safe (potential for fall and injuries) to be by himself for toileting and lower body dressing because the resident could not perform those tasks safely by himself. The OT further stated if the resident was assessed to be safe, she would document "independent" in her assessment instead of CGA and SBA. The OT stated according to the resident's condition and her assessment, staff needs to be with the resident at all times during toileting because it was not safe for the resident to be by himself. On 8/22/14, at 3:15 p.m., during an interview, the licensed vocational nurse (LVN 1) stated while she was passing her morning medication she heard a loud noise coming from Resident 1's room. LVN 1 stated as she rushed into the resident's room and opened the bathroom's door, she saw the resident lying on the floor on his left side. LVN 1 stated that at that time, there was no other staff with the resident or near by the resident's room. LVN 1 stated that Resident 1 was able to perform some tasks by himself, but for toileting, the resident needed supervision (staff to be there with the resident.) LVN 1 stated even when the resident asked staff to provide privacy, staff needed to provide privacy by closing the bathroom door, but to stay in the room with the resident to periodically check on the resident for safety. LVN 1 stated after the resident fell, she asked CNA 1 why she did not stay in the room to check and help Resident 1. CNA 1 stated she left the room because other residents called her for help. A review of the physician's order, dated 8/4/14, indicated to obtain a left hip x-ray STAT (immediately). A review of Resident 1's final x-ray report, dated 8/4/14, indicated that the resident sustained an acute intertrochanteric (hip) fracture with mild displacement (the bone snapped into two or more parts and moved so that the two ends of the bones were not lined up straight.) A review of a physician's order, dated 8/4/14, at 11:38 a.m., indicated to transfer the resident to a general acute care hospital (GACH) emergency room for further evaluation due to the resident complaining of left hip pain. A review of the emergency department triage note, dated 8/04/14, at 1:03 p.m., indicated that Resident 1 arrived from the nursing home for a slip and mechanical ground level fall in the bathroom, leading to injury to left hip. The resident complained of left hip pain, rating 7 on a scale of 0 to 10 (0 = no pain, 7 = severe pain, and 10 = unimaginable pain.) The resident received Ultram, a pain medication, 50 milligrams (mgs) tablet one time for left hip pain. A review of the GACH's medication record, dated 8/4/15 to 8/6/14, indicated that Resident 1 required and received four dosages of morphine (pain medication) 2 mgs via intravenous push (IVP) for severe pain, and seven dosages of Norco (a pain medication) 5/325 mg tablets by mouth for moderate pain. A review of the GACH's orthopedic consultation report, dated 8/4/14, indicated that Resident 1 sustained a left hip fracture after a fall at the skilled nursing facility where he resides. The report indicated that the resident's pain may be treated conservatively with bed rest for 2-4 weeks, pain control, and serial radiographs (x-ray) on a weekly basic due to multiple medical problems. According to the report, surgery may still be done in the near future if the fracture should displace or the resident had severe hip pain. A review of the facility's investigation report, dated 8/4/14, indicated that the resident had the capacity to understand and make decisions. The resident was aware that he needed assistance and he understood the risks and consequences, including a fall with serious injury. The resident stood up and tried to pull his underwear without calling for help, as a result he fell and sustained a hip fracture. A review of the interdisciplinary team (IDT) notes, dated 6/30/14 and 7/8/14 (prior to the fall incident) indicated that there was no documentation regarding the team's identifying Resident 1's refusal of staff's help during toileting, and/or risks regarding fall being explained to the resident. There was also no documented evidence that the staff providing care was aware or followed through with the Occupational Therapist?s (OT) assessment that indicated that the resident was not safe (potential for fall and injuries) to be by himself for toileting and lower body dressing because the resident could not perform those tasks safely by himself.A review of the facility's policy and procedure titled, "Routine Nursing Care," dated 1/1/2002, indicated that toileting-assistance will be provided for all residents at a level determined by the functional skills of the resident. According to the facility's undated policy and procedure titled, "Assisting a Resident to walk to the Bathroom," provide the resident with as much privacy as possible; tell the resident to call or signaled for you; wait outside the door, if permitted. A review of the "Occupational Therapy Evaluation and Plan of Treatment", dated 8/12/14, indicated the resident was readmitted to the facility after being admitted to the hospital secondary to a fall and subsequent hip fracture on the left hip resulting in no out of bed activity by the doctors and conservative hip fracture management with complete bed rest. Therefore, the facility failed to ensure that Resident 1, a left leg amputee who was assessed as being at high risk for falls and needed extensive assistance from staff during toileting, received adequate supervision to prevent fall and injury. And as result, Resident 1 who was left unsupervised in the bathroom, stood up to pull his underwear, fell to the floor and sustained an acute intertrochanteric (hip) fracture with mild displacement.The above violation presented an imminent danger that death or serious harm to the resident would result therefrom, and it did. |
| 940000096 |
Royal Care Skilled Nursing Center |
940011365 |
B |
20-Apr-15 |
217W11 |
6976 |
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 Department received an entity reported incident (ERI) from the facility on February 13, 2013. The ERI indicated on February 11, 2013, a patient (Patient A) was slapped by a certified nurse assistant (CNA1). According to a letter, dated February 11, 2013, the patient had no injuries. The letter further indicated no other patients were given care by CNA1 had any injuries or complaints.Based on interviews and record reviews, the facility?s staff failed to: Follow its policy regarding abuse reporting, by the staff (CNA2) not reporting Patient A?s abuse allegation to the supervisor staff. This failure put Patient A and other patients at risk for abuse. On February 19, 2013, an unannounced entity reported incident/complaint investigation was initiated and on January 23, 2015, a follow-up investigation was conducted. A review of the facility?s document, titled, ?Verification of Incident Investigation/Administrative Summary,? written by the administrator, indicated on February 9, 2013, Patient B (Patient A?s roommate) heard what sounded like a slap and a comment to Patient A, by CNA1, ?That was what you get; I am only trying to help you.? A further review of the summary, indicated on February 14, 2013 (three days after the incident), CNA2 made a statement to the administrator that Patient A told her CNA1 had hit her.A review of CNA1?s undated written statement indicated he had gone into Patient A?s room to get her ready for a shower. According to the written statement, he took her to the shower and while showering the patient, she reached for the shower head and hit herself in the eye. The statement indicated he reported the injury to the charge nurse, LVN1. LVN1 documented she assessed the patient?s eye injury. The note indicated she notified the patient?s doctor and responsible party about the injury. A review of a form titled, ?Report of Incident,? dated February 9, 2013, indicated the patient had an injury to the left eye. The report indicated CNA1 reported while showering Patient A, she accidentally hit her face and sustained a slight discoloration to her left eye. The report indicated Patient A was unable to tell what happened to her eye secondary to impaired cognition.A review of Patient A?s medical record indicated she was an 84 year-old female admitted to the facility on January 15, 2013. Her diagnoses included hypertension (high blood pressure), urinary tract infection (infection of the kidney, ureter, bladder, or urethra) and syncope episodes (fainting or passing out). A review of the Minimum Data Set (MDS), an assessment and care screening tool, dated February 10, 2013, indicated the patient usually understands, but had difficulty communicating some words or finishing thoughts, but was able if prompted, or given time. The MDS also indicated the patient misses some part/intent of message, but comprehends most conversations and for one to three days patient exhibited hitting, kicking, pushing, scratching, and grabbing. Patient A was assessed as needing extensive assistance with her activities of daily living (ADL) and required a two-person assist with transferring and bed mobility.An attempt to interview the previous administrator (ADM1) was unsuccessful, secondary to the administrator no longer being employed at the facility. On January 23, 2015, at approximately 11 a.m., during an interview, the medical records staff member (MR1) stated she was off duty the weekend of the incident and returned the following Monday. According to MR1, CNA2 reported to her that CNA1 had slapped Patient A. MRI stated she asked CNA2 if she had reported the abuse and she told her not yet. MR1 stated she then went to report the abuse to the administrator.A review of a form titled, ?Facility Training Tracking System for Abuse & Reporting,? dated February 6, 2013, indicated both CNAs 1 and 2 signed their names as attendees for the training. A review of CNA 1 and 2?s personnel files indicated both had been terminated on February 19, 2013. CNA1?s file indicated he was terminated for not following resident rights and a failure to report details of incident to the charge nurse. CNA2 was terminated for failing to report the alleged abuse during the mandated time frame.A review of the facility?s policy titled, ?Abuse Prevention, Intervention, Investigation & Crime Reporting, Policy No. 6, Reporting indicated the facility required the employees to immediately report the facts of known or suspected instances of abuse. The policy stipulated all allegations of abuse and suspicions of crime should be immediately reported to the facility?s administrator. The facility?s responsibility was to protect residents and promptly investigate all occurrences.On February 18, 2015, at 8 a.m., during a telephone interview, CNA2, who was terminated from the facility, indicated she was assigned to Patient A the weekend of the incident. CNA2 stated she asked Patient A what happened to her eye and the patient told her CNA1 hit her.CNA2 stated she did not report what the patient stated until the following Monday, because she was very busy and forgot.On February 18, 2015, at approximately 3:20 p.m., an interview with Patient B (Patient A?s former roommate) was conducted. According to Patient B, she remembered the incident ?liked it was yesterday.? She stated Patient A was being attended to by CNA1 because he had come to shower Patient A. CNA1 pulled the privacy curtain and about a minute later she heard what sounded like a slap and Patient A crying. Patient B stated afterwards CNA1 told Patient A, ?That is what you get.? CNA1 took Patient A out of the room and later heard CNA1 saying that Patient A, ?Did it to herself.? Patient B stated the charge nurse came into the room and looked at Patient A and left. When asked if the nurse spoke to her about Patient A, she stated, ?No.? When Patient B was asked why she did not immediately report CNA1 she stated she was not scared for herself, but for Patient A because she thought CNA1 might come back and hit Patient A again.A review of Patient B?s medical record indicated she was admitted to the facility with diagnoses that included right knee wound infection. A review of her MDS, dated February 6, 2013, indicated Patient B had no long or short-term memory problems. Patient B was discharged home on April 20, 2013, because her health had improved and no longer needed services provided by the facility. The facility?s staff failed to: Follow its policy regarding abuse reporting, by the staff (CNA2) not reporting Patient A?s abuse allegations to the supervisor staff.The above violation had a direct or immediate relationship to the health, safety, or security of Patient A. |
| 950000007 |
Ramona Nursing & Rehabilitation Center |
940011388 |
A |
04-May-15 |
PWXR11 |
13713 |
F309 ? 42 CFR 483.25 Quality of Care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.On 7/9/14 at 7 a.m., an unannounced visit was made to the facility to investigate an entity self-reported incident regarding Resident 1's death at the facility.The facility failed to ensure the staff immediately initiated cardiopulmonary resuscitation (CPR, a lifesaving technique useful in many emergencies) with uninterrupted chest compressions, airway check, and provision of rescue breathing, when Resident 1 was found on the floor, unresponsive, with a weak pulse, and not breathing, in accordance with the facility?s policy and procedure.Resident 1, who had a full code status (the provision of a full cardiopulmonary resuscitation) in the event of a medical emergency, was found by Certified Nursing Attendant (CNA) 1 to be unresponsive, face down on the floor in his room. CNA 1 did not immediately initiate CPR on Resident 1after calling the licensed vocational nurse (LVN 1) for assistance. CNA 1 assisted in placing the resident back to bed and was cleaning the resident instead. LVN 1 went into Resident 1?s room, found the resident face down on the floor, and assessed the resident as unresponsive and not breathing. After calling the registered nurse (RN 1) for assistance, LVN 1 ran out of the resident?s room to get the pulse oximetry (a machine used to measure the oxygen level in the blood), and the blood glucose monitoring machine (checks the level of sugar in the blood) instead of immediately initiating CPR. RN 1 found the resident on the floor, unresponsive, with a weak pulse, and not breathing. Instead of immediately initiating CPR, RN 1 instructed CNA 1 and 2 to place the resident back to his bed, and left the resident?s room to get an oxygen tank and check the clinical record for the resident?s code status. After identifying the resident's code status as full code, RN 1 called the paramedics and instructed the staff to initiate CPR.The delay in initiating CPR resulted in Resident 1 going into cardiopulmonary arrest that led to his death. The clinical records indicated Resident 1 was admitted to the facility on 6/11/14, with the diagnoses which included diabetes (high blood sugar), and hypertension (high blood pressure). The Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/19/14, indicated Resident 1 was alert and oriented; needed extensive assistance (staff provide weight bearing support) from staff for toileting and personal hygiene; and was frequently incontinent (lose control) of bowel and bladder functions. The Physician Orders for Life Sustaining Treatment (POLST, a form created for specific medical orders to be honored by health care workers during a medical crisis), dated 6/12/14, indicated Resident 1's legal decision maker indicated to perform CPR on Resident 1 in case of a medical emergency.The Licensed Personnel Weekly Progress Notes, dated 7/4/14 at 4:50 p.m., indicated the registered nurse (RN 1) was called to Resident 1's room and RN 1 saw the resident lying on the floor. The progress notes indicated the staff placed the resident on the bed and noted there was injury to the resident?s mid forehead with minimal bleeding. First aid was provided to the resident. The resident was unresponsive at this time but RN 1 was able to palpate (feel) a weak carotid pulse. The notes did not indicate how weak Resident 1's pulse was. The Licensed Personnel Weekly Progress Notes, dated 7/4/14 at 4:52 p.m., indicated RN 1 documented that Resident 1's oxygen saturation (a measurement of the amount of oxygen the blood is carrying) was at 80 percent on room air (normal range is 95-100 percent). The progress notes indicated the resident was given oxygen at 15 liters per minute using a non-rebreather mask (a device used in medical emergencies that required oxygen therapy and when the patient can breathe unassisted) and the resident?s oxygen saturation went up to 87 percent only.The progress notes indicated Resident 1's blood pressure, respirations, and the carotid pulse could not be obtained. The notes indicated CPR was initiated by other staff while RN 1 called the paramedics for assistance. At 4:55 p.m., the paramedics arrived, the facility gave report to the paramedics, and the paramedics took over the treatment. At 5 p.m., the paramedic pronounced the resident as expired and with asystole (absence of heartbeat) from the electrocardiogram (EKG, a test that checks for problems with the electrical activity of the heart) result. According to the death certificate, Resident 1's place of death was at the facility and the immediate cause of death was cardiopulmonary arrest (a sudden stop in effective blood circulation due to failure of the heart to contract effectively or not contracting at all). The facility's policy and procedures titled, ?Emergency Procedure - Cardiopulmonary Resuscitation,? dated 4/2011, indicated cardiac arrest is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body. The chances of surviving a sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. Any unnecessary interruptions in chest compressions decrease CPR effectiveness. If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless it is known that a do not resuscitate order (do not do CPR) and or there are obvious signs of irreversible death. The facility shall designate a team leader who is responsible for coordinating the rescue effort and directing other team members during the rescue effort.The facility's policy also indicated the procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility basic life support (BLS) training material. The BLS sequence of events referred to as C-A-D (chest compressions, airway, and breathing) is initiated when the adult victim is unresponsive and not breathing normally without assessing the victim's pulse.A review of the American Heart Association Adult Basic Life Support for Healthcare Providers (a quick reference), dated 2011, indicated when the resident is unresponsive, not breathing or has no normal breathing, first activate emergency response system (call for help or send someone to get help). Check the pulse. If there is definite pulse, give 1 breath every 5 - 6 seconds, and recheck the pulse every 2 minutes. If there is no pulse, begin cycle of 30 chest compressions, followed by 2 breaths, and keep repeating until help arrives. On 7/9/14 at 7:10 a.m., in an interview with the director of nursing (DON), she stated that on 7/4/14, during the 3-11 shift, Resident 2 flagged the certified nursing assistant (CNA 1) stating, "Man down." The DON stated when CNA 1 entered Resident 1's room, she found Resident 1 lying face down on the floor with the lower half of his body in the bathroom and the upper half in the room. The DON stated CNA 1 then called the licensed vocational nurse (LVN 1), and with the assistance of RN 1, they performed CPR and called the paramedics. When the paramedics arrived at the scene, they stated the resident had expired. On 7/9/14 at 8 a.m., in an interview with Resident 2, she stated as she was standing in the doorway, she witnessed Resident 1 crashing down to the floor without saying anything. She then flagged a nurse to come and help. On 7/9/14 at 10:20 a.m., CNA 1 stated she was flagged by Resident 2, who was stating, "Man down." CNA 1 stated she saw Resident 1 face down on the floor, unresponsive. CNA 1 stated she called LVN 1 on her communication radio and went to the door to flag LVN 1 down. When asked if she initiated CPR at that time, she stated, ?No.? CNA 1 stated LVN 1 came to Resident 1?s room and both of them tried to take the resident?s vital signs, but they were not able to obtain them. CNA 1 stated RN 1 called CNA 2 to help put the resident to bed. When they put the resident to bed, the resident was observed to have blood on his face and bowel movement on his shirt. CNA 1 stated she tried cleaning him up. CNA 1 stated LVN 1 did not start CPR at the time because RN 1 and LVN 1 left the room to get an oxygen tank. CNA 1 stated she also noticed the big oxygen tank brought in by RN 1 was kind of low on oxygen.On 7/9/14 at 9:27 a.m., LVN 1 stated she was a couple of rooms down the hallway when CNA 1 flagged her to Resident 1's room. When she entered the room, she saw Resident 1 face down on the floor and wearing only a shirt. LVN 1 stated the resident was not responding and/or breathing. LVN 1 stated when she opened one of the resident's eyes, the eye was not moving. When asked if she started CPR at that time, LVN 1 stated, ?No.?According to LVN 1, she called RN 1 on her communication radio to come to Resident 1's room, and when RN 1 inquired about the resident's blood sugar levels, LVN 1 stated she ran out of the room to get the pulse oximetry and the blood glucose monitoring machine to bring back to the resident?s room. LVN 1 stated when she returned to the room, she saw RN 1 had brought a large oxygen tank, but she (LVN 1) told RN 1 the large oxygen tank was not going to work because it did not have enough oxygen. RN 1 then asked for another tank. According to LVN 1, she and RN 1 left Resident 1 in order to get another tank. On 7/9/14 at 10:48 a.m., CNA 2 stated on the day of the incident, he was called on the communication radio to go to Resident 1?s room to assist the other staff in putting him back to bed. CNA 2 stated the resident's carotid (neck) pulse was very weak, and at the same time, LVN 1 told them the resident was not breathing. CNA 2 stated LVN 1 was checking for the resident's blood sugar levels at the same time RN 1 brought a large oxygen tank, which he thought was kind of empty.According to CNA 2, they did not start CPR because RN 1 and LVN 1 both left the room to get a smaller oxygen tank and an oxygen concentrator.During the interview, CNA 2 was asked if anyone started CPR by starting chest compressions when the resident was not breathing and had a very, very weak pulse, CNA 2 stated, ?No.?According to CNA 2, right before the paramedics arrived, he was told to start CPR by doing chest compressions while LVN 1 delivered oxygen using an ambu bag (a self-inflating bag that is hand-held used to provide oxygen to patients who are not breathing or not breathing adequately). CNA 2 stated he started CPR before the paramedic's arrival and once they arrived, the paramedics told him to stop because they wanted to hook the resident up to a machine.On 7/31/14 at 2:30 p.m., during an interview, RN 1 stated that on 7/4/14 at 4:50 p.m., LVN 1 called her to go to Resident 1's room, so she grabbed a big oxygen tank, and asked LVN 1 about the resident's blood sugar levels because the resident had a hypoglycemic (low blood sugar) reaction before. RN 1 stated when she entered the resident?s room, the resident was still lying on the floor. She tapped the resident's shoulders several times and called out his name but the resident was not responding and was not breathing. So, RN 1 stated she instructed the staff to place the resident on the bed. Further interview with RN 1 indicated she left Resident 1's room to check his code status. When RN 1 found that Resident 1?s code status was full code, that was the time when she called the paramedics for assistance. RN 1 stated since the big oxygen tank she brought initially inside the resident?s room was almost empty, upon return to the resident?s room, she grabbed another oxygen tank. At that time, LVN 1 told her (RN 1) that the resident's oxygen saturation was at 85 percent.According to RN 1, they then administered oxygen using a non-breather mask and started CPR on Resident 1. RN 1 stated that shortly after they started CPR, the paramedics arrived and she told a staff to take over (the CPR) in order to answer the paramedics' questions. According to RN 1, the paramedics then connected the resident to the electrocardiogram (EKG) machine. At 5 p.m., the paramedics stated the resident had expired. During the interview, RN 1 stated she was the designated team leader responsible for directing team members during the code. RN 1 was asked that instead of leaving the resident, could she have asked someone else to gather the supplies and to check the chart for the resident's code status, she paused and stated, "I guess yes." RN 1 was also asked why she did not instruct CNA 1 and LVN 1 to start the CPR when they first found the resident unresponsive and not breathing, she stated because the resident had a weak pulse. When RN 1 was asked how weak (or how many beats per minute) the resident's pulse was, she stated it was just very weak.Therefore, the facility failed to ensure the staff immediately initiated cardiopulmonary resuscitation (CPR, a lifesaving technique useful in many emergencies) with uninterrupted chest compressions, airway check, and provision of rescue breathing, when Resident 1 was found on the floor, unresponsive, with a weak pulse, and not breathing, in accordance with the facility?s policy and procedure.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. |
| 940000095 |
RIVIERA HEALTHCARE CENTER |
940011911 |
A |
21-Jan-16 |
G34911 |
7888 |
CFR ? 483.25 F309 Quality of CareEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to: 1. Identify Resident 1's risk for wandering with aggressive behavioral symptoms, and 2. Develop a care plan including the need for supervision and psychiatric evaluation.As a result of the above failures, Resident 1 wandered into Resident 2's room and provoked Resident 2 that caused Resident 2 to hit Resident 1. Resident 1 was transferred to a hospital emergency room (ER) for evaluation and treatment. The brain scan showed Resident 1 sustained a sub-acute (recent onset) subdural hematoma (collection of blood outside the brain due to a head injury) with a midline shift of the brain to the left, and a fracture of the right temporal bone (side of the skull) requiring brain surgery.A review of the Face Sheet (admission record) indicated Resident 1 was readmitted to the facility on May 19, 2014. Resident 1's diagnoses included dementia (loss of brain function that affects memory, thinking, judgment, and behavior). The Minimum Data Set (MDS), a resident assessment and care screening tool, dated March 17, 2014, indicated Resident 1 was severely impaired in cognitive skills (mental ability) for daily decision making with short and long-term memory problems. Resident 1 required extensive assistance (staff provided weight bearing support and at times required full staff performance) from staff with transfer, personal hygiene, and toilet use. The MDS indicated Resident 1used a wheelchair to get around the facility and had physical behavioral symptoms directed toward others.A review of Resident 1's clinical record indicated a physician's order, dated May 12, 2014, to transfer Resident 1 to the hospital due to combative behavior, hitting staff and other residents.A review of Resident 1's physician's readmission order, dated May 19, 2014, indicated: 1. Administer Seroquel (a psychotropic medication, any medication capable of affecting the mind, emotions, and behavior) 25 milligrams po (orally) BID (twice a day) for dementia with psychosis (a mental disorder involving loss of contact with reality) manifested by striking out.2. Psychiatry evaluation and treatment as needed based on psychotropic medications and psychiatric diagnosis or behavior manifestation. A review of Resident 1's clinical record revealed there was no documented evidence the facility obtained psychiatric evaluation and treatment for the resident. There was no documentation of an interdisciplinary team (IDT, a group consisting of the head of the different departments who work together to discuss a resident's care) conference addressing Resident 1's aggressive behaviors and wandering behavior into other residents' rooms and no care plan was developed.A review of the facility's investigation report, dated July 6, 2014, at 3:45 p.m., indicated a certified nursing assistant (CNA 1) saw Resident 1 in Resident 2's room and they were fighting inside the room. Both residents were separated and assessed. Resident 1 sustained a cut to the bridge of his nose with some bleeding and was transferred to the hospital for possible nose fracture. A review of the Interdisciplinary Team Conference Record, dated July 7, 2014, indicated Resident 2 admitted he hit Resident 1 because he was provoked by Resident1.A review of Resident 1's Final Radiology Report of the brain scan dated July 6, 2014, indicated he sustained a sub-acute subdural hematoma measuring 14.5 centimeters ([cm], 2.54 cm = 1 inch) in length and 1.6 cm in width with active bleeding. The report indicated there was a 6 millimeter ([mm], 10 mm = 1 cm) midline shift of the brain to the left and a fracture of the temporal bone on the right.A review of the hospital's Physician History and Physical (H & P) Record, dated July 6, 2014, indicated Resident 1 would be transferred to another hospital for brain surgery.On July 15, 2014, at 2:30 p.m., Resident 2 was observed in the patio area wheeling himself around with his right hand. Resident 2 stated he had an incident with Resident 1 where Resident 1 was blocking the doorway and told Resident 2 he should speak Spanish only. Resident 2 responded back stating that he speaks multiple languages and Resident 1 got upset; started cursing at him. Resident 2 stated Resident 1 tried to swing at him, so he made a closed tight fist and punched Resident 1 in the face. Resident 2 stated that when he was younger, he used to practice boxing and worked as a mechanic, so his right arm was very strong. When Resident 2 was asked if he was aware that Resident 1 was confused he responded that he did and that he did not feel bad about what happened because he was provoked. A review of the Face Sheet indicated Resident 2 was admitted to the facility on June 6, 2010, with diagnoses that included late effect- hemiplegia (paralysis affecting only one side of the body) non-dominant side.The MDS, dated June 4, 2014, indicated Resident 2 was cognitively intact for daily decision making and had no behavioral symptoms. Resident 2 required extensive assistance from staff with transfer, personal hygiene, and toilet use. The MDS indicated Resident 2 used a wheelchair to get around the facility.On July 15, 2014, at 3:20 p.m., during an interview with CNA 1, she stated she was the one who saw Resident 1 in Resident 2's room on July 6, 2014, when they were fighting. When CNA 1 was asked if Resident 1 had gone into other residents' rooms, she responded, "Yes, always."During an interview on July 16, 2014, at 3:20 p.m., licensed vocational nurse (LVN 1) stated Resident 1 was very confused due to his dementia, where he frequently gets aggressive with staff and other residents. LVN 1 stated Resident 1 often would enter into other residents' rooms and the residents would sometimes get upset. When asked if there was a care plan addressing Resident 1's wandering behavior and safety risk, LVN 1 stated, "No, I can't find one in the chart (clinical record)."A review of the facility's policy and procedure titled, "Care Planning, Patient Conference", dated February 14, 2011, indicated the functions/responsibilities of the IDT are to complete a comprehensive assessment and develop a plan of care for new admissions within 14 days.A review of the facility's policy and procedure titled, "Care Planning & Patient Assessment", dated February 14, 2011, indicated the purpose of the policy is to identify the needs and to provide a data base to be used in planning the comprehensive nursing care to meet patient's individual needs.On July 17, 2014, at 3:45 p.m., Resident 1's clinical record was reviewed with the director of nursing (DON), who could not provide documentation of a care plan and IDT meeting addressing Resident 1's wandering behavior. The DON stated there should be a care plan and an IDT meeting to address Resident 1's aggressive behaviors with other residents and the risk of unsafe wandering. The DON stated she was not aware Resident 1 did not get the psychiatric evaluation because per policy, Resident 1 should automatically have had one since he was on psychotropic medications (medication capable of affecting the mind, emotions, and behavior) and had behavioral problems.Therefore, the facility failed to: 1. Identify Resident 1's risk for wandering with aggressive behavioral symptoms, and 2. Develop a care plan including the need for supervision and psychiatric evaluation.The above violation presented either imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 940000095 |
RIVIERA HEALTHCARE CENTER |
940011982 |
B |
21-Jan-16 |
G34911 |
4566 |
CFR 483.13 (c) (2) F225- 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). HSC: 1418.91 Reports of incidents of alleged abuse or suspected abuse of residents (a) A long -term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. The Department received a complaint on July 14, 2014, regarding a resident (Resident 2) hitting another resident (Resident 1) at the skilled nursing facility (SNF).On July 15, 2014, an unannounced visit was made to the SNF to investigate the complaint. The facility failed to: 1. Report a physical abuse incident to the Department of Health within 24 hours of the incident.Resident 2 hit Resident 1 when Resident 1 wandered into Resident 2?s room. Resident 1 was transferred to a hospital emergency room (ER) for evaluation and treatment. The brain scan showed Resident 1 sustained a sub-acute (recent onset) subdural hematoma (collection of blood outside the brain due to a head injury) with a midline shift of the brain to the left, and a fracture of the right temporal bone (side of the skull) requiring brain surgery.A review of Resident 1's Face Sheet (admission record) indicated he was admitted to the facility on March 10, 2014. Resident 1's diagnoses included dementia (loss of brain function that affects memory, thinking, judgment, and behavior). The Minimum Data Set (MDS), a resident assessment and care screening tool, dated March 17, 2014, indicated Resident 1 was severely impaired in cognitive skills (mental ability) for daily decision making with short and long-term memory problems, and was using a wheelchair to get around the facility. The MDS indicated Resident 1 had physical behavioral symptoms directed toward others.A review of the facility's investigation report, dated July 6, 2014, at 3:45 p.m., indicated a certified nursing assistant (CNA 1) saw Resident 1 in Resident 2's room and they were fighting inside the room. Both residents were separated and assessed. Resident 1 sustained a cut to the bridge of his nose with some bleeding and was transferred to the hospital for possible nose fracture.A review of Resident 1's Final Radiology Report of the brain scan, dated July 6, 2014, indicated he sustained a sub-acute subdural hematoma measuring 14.5 centimeters (cm) in length and 1.6 cm in width with active bleeding and a 6 millimeter (mm) midline shift of the brain to the left and a fracture of the temporal bone on the right.The hospital's Physician History and Physical (H & P) Record, dated July 6, 2014, indicated Resident 1 would be transferred to another hospital for brain surgery.A review of Resident 2's Face Sheet (admission record) indicated he was admitted to the facility on June 6, 2010. Resident 2's diagnoses included hemiplegia (paralysis affecting one side of the body) non-dominant side. The MDS, dated June 4, 2014, indicated Resident 2 was mentally intact and had the ability to understand and be understood. The MDS indicated Resident 2 had no behavioral symptoms and no indicators of psychosis (a mental disorder).On July 15, 2014, at 2:10 p.m., during an interview with the administrator, he stated the altercation between Residents 1 and 2 should have been reported to the Department of Health Services within 24 hours of the incident. The administrator stated he forgot to report the incident.On July 15, 2014, at 2:30 p.m., Resident 2 stated Resident 1 tried to swing at him, so he made a closed tight fist and punched Resident 1 in the face. Resident 2 stated he was aware that Resident 1 was confused, and did not feel bad about what happened because he was provoked. A review of the facility?s policy and procedure titled, ?Elder Abuse- Investigation/Reporting,? dated July 20, 2007, indicated the administrator or designee will notify the Department of Health Services, Licensing and Certification within 24 hours of learning of the alleged abuse.The facility failed to: 1. Report a physical abuse incident to the Department of Health Services within 24 hours of the incident.The above violation had a direct relationship to the health, safety, or security of Resident 1. |
| 940000014 |
Rose Villa Healthcare Center |
940011990 |
A |
12-Feb-16 |
MP8811 |
16203 |
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, alleging that a resident (Resident 1), who was receiving oxygen (O2) via a nasal cannula, was using his cigarette lighter to see if it worked, so he could smoke later. The action resulted in facial burns that required a transfer to a general acute care hospital (GACH). The facility failed to ensure the residents environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure regarding smoking. 2. Failure to provide smoking safety education to family members and Residents 1, 4, and 5, who smoked, especially regarding smoking and oxygen usage. 3. Failure to ensure residents did not have smoking materials at the bedside.Resident 1, who was receiving oxygen (O2) via nasal cannula (plastic prong tubing placed in nose attached to an oxygen canister),was playing with a lighter on 12/11/14, at 1:40 a.m., in his room while in bed. When the resident flicked the lighter, the oxygen exploded resulting in facial burns on Resident 1.As a result of these deficient practices Resident 1 sustained first and second degree burns (first-degree burns affect only the outer layer of the skin and second-degree burns affect both the outer and underlying layer of the skin, both degree of burns results in pain, redness, swelling, but blistering [partial thickness burns]) is included in second degree burns) to the resident's face and nasal passages, which had a potential to compromise Resident 1's airway and put the resident's roommate and other residents, visitors and staff in danger. Resident 1 required a transfer to two hospitals. Resident 1 was treated with narcotic pain medications, breathing treatments, wound dressings, while the resident?s airway patency was closely monitored.These deficient practices also put Residents 4 and 5 at risk for harm, due to the lack of education and adhering to the facility?s policy and procedure.On 12/12/14, at 1:50 p.m., during the unannounced ERI investigation, Resident 1 was not observed in his room. At 1:55 p.m., on 12/12/14, during an interview, the director of nurses (DON) stated Resident 1 was transferred to GACH 1 and then to GACH 2, due to the need for a higher level of care of the facial burns.The DON was asked for a list of residents who smoked and six residents were identified. Residents 4 and 5 were interviewed.a. A review of Resident 1's Admission Record (face sheet) indicated the resident was a 68 year-old male, who was admitted to the facility on 9/8/14. Resident 1's diagnoses included generalized muscle weakness, diabetes mellitus (high blood glucose/sugar), blindness on one eye, syncope (temporary loss of consciousness/faintness/drop in blood pressure) and collapse.A review of a Minimum Data Set (MDS), a standardized assessment and screening tool, dated 9/15/14, indicated Resident 1 was cognitively impaired (mental processes of perception, memory, judgment, and reasoning). According to the MDS, Resident 1 required extensive assistance (staff provide weight-bearing support) from staff with a two- person physical assist for bed mobility, transferring, and toilet use.Resident 1 had impairment of both upper extremities (arms). The resident used both a walker and wheelchair as mobility aids.A review of a physician's order, dated 9/17/14, indicated to give Resident 1 two liters of O2 via nasal cannula as needed for shortness of breath, and to keep the O2 saturation (concentration of oxygen in blood) above 94 percent (%).A review of a nurse's progress note, dated 12/11/14, and timed at 1:40 a.m., indicated a licensed vocational nurse (LVN 1) heard an unusual noise, followed by a burning smell near Room 10. The nurse's progress note indicated LVN1 entered Resident 1's room (Room 8) and noted the resident was in bed with a burnt nasal cannula and black powder on his face. LVN1 immediately turned the O2 concentration off and assessed the resident's condition; LVN1 assessed Resident 1 to have burned marks on his nose, cheeks, and forehead. The progress note indicated LVN1 rendered first aid, and then removed the cigarettes and the lighter from Resident 1.On 12/12/14, at 4:15 p.m., during a telephone interview, LVN1 stated he worked during the night shift on 11 p.m.-7 a.m., from 12/10/14 to 12/11/14. LVN 1 stated at approximately 1:40 a.m., he heard an unusual swishing sound. LVN 1 stated when he followed the sound to the Resident 1's room, he smelled burnt hair, and saw the resident's face was covered in black powder with a disfigured nasal cannula still in Resident 1's nose. LVN1 stated he found unlit cigarettes in the resident's pockets and Resident 1 stated that he made a mistake of mixing oxygen and the cigarettes. A review of a nurse's progress notes, dated 12/11/14, and timed at 3 p.m., indicated Resident 1 was transferred to the GACH via paramedics.On 12/12/14 at 5 p.m., while at the facility, Resident 1 was observed returning to the facility from the GACH, lying on a gurney.At 5:05 p.m., on 12/12/14, Resident 1 was observed sitting in his bed with a Vaseline gauze (a fine mesh, absorbent gauze with white petrolatum; keeps wound moist, usually used for burns) covering the resident's bilateral (both) cheeks and nose.On 12/12/14, at 5:08 p.m., during an interview, Resident 1 stated that he was trying to test his lighter to make sure it worked and he burnt himself because he forgot that he had the oxygen on. Resident 1 stated he brought the lighter with him upon admission three months prior and that the facility's staff did not educate him regarding the facility's safety smoking policy. Resident 1 stated the staff never told him he could not have his lighter and/or cigarettes at the bedside.A review of GACH 1's record, indicated Resident 1 was seen at the hospital after the flash burn ([flash flame explosion] any burn injury caused by intense flashes of light, high voltage electric current, or strong thermal radiation) to the face while Resident 1 was trying to light a cigarette with oxygen via nasal cannula in place. According to GACH 1's records, Resident 1 was transferred from GACH 1 to GACH 2 (a higher level of care hospital) on 12/11/14.According to GACH 2's records, Resident 1 was admitted for monitoring of the resident's airway, due an abnormal finding on the chest x-ray. According to the chest x-ray, the resident's broncho-vascular area (lungs/bronchioles [part of the respiratory system anatomy]) had increased markings (indicative of an increase in fluid or edema). Resident 1 had coarse breath sounds with bilaterally (both lungs) wheezing (a high-pitched whistling sound made while breathing) in both upper lobes of the resident's lungs. Resident 1 required respiratory breathing treatments of Duoneb/mucomyst (use to relax muscles in the airways and increase air flow to the lungs/ for abnormal mucous secretions). Resident 1 was pre-medicated with Oxycodone (narcotic/pain medication) by mouth prior to resident's face being washed with soap and water; bacitracin (an antibiotic ointment) was applied to the resident's facial open areas, and covered with Vaseline gauze and burn netting. GACH 2's plan of care for Resident 1 included the above daily wound treatment at the SNF for 14 days, followed-up with an appointment at an outpatient burn clinic.On 12/19/15, at 3 p.m., during an interview, the facility's social worker (SW) stated the morning Resident 1 was burned she found two lighters and cigarettes at Resident 1's bedside. The SW stated she educated residents and their family members regarding the facility's smoking safety. The SW stated the residents could not keep cigarettes and lighters with them and she stated she had educated Resident 1's family member to not to give cigarettes and lighters to the resident.On 12/19/14, at 3:15 p.m., Resident 1 stated he was now famous at the facility and because of him; the facility's smoking policy had changed. Resident 1 stated no one at the facility told him that he was not supposed to keep his lighter and cigarettes. Resident 1 stated there were no rules about smoking before he burnt himself. Resident 1 stated he would go to the facility's patio and smoke whenever he wanted. Resident 1 stated now he has to adhere to a smoking schedule and have to be supervised by the staff when he smoked. When Resident 1 was asked how he obtained the cigarettes, Resident 1 stated his family member (FM 2) brought him two packs of cigarettes every weekend.On 12/19/14, at 3:40 p.m., during a telephone interview, FM 2 stated she would give Resident 1 cigarettes every time she visited. When FM2 was asked if someone at the facility had provided education regarding smoking safety and to not to provide Resident 1 with cigarettes and lighters, FM 2 stated the facility's staff only informed her not to give Resident 1 cigarettes and lighters after the burned incident.At 4:15 p.m., on 12/19/15, during an interview, LVN 2 stated the residents were not supposed to keep cigarettes and lighters. LVN 2 stated it was the facility's staff responsibility to remove the cigarettes and lighters from the residents. A review of Resident 1's nursing care plan, dated 9/17/14, and titled, "Potential for injury R/T (related) to smoking," indicated the resident had potential for injury related to smoking. The goal was for Resident 1 to be compliant with the smoking protocols and an individual smoking plan. The nursing interventions included the facility's staff to explain the smoking policy, educate the resident's family member to ensure they gave all smoking materials to staff for safe keeping, monitor to assess the resident's compliance with the facility's smoking policy and individual plan, and to report non-compliance or unsafe smoking habits to the resident's physician and responsible party.A review of a smoking assessment for Resident 1, dated 9/17/14, indicated the resident had no cognitive, vision, or balance deficit. The assessment indicated Resident 1 smoked morning, afternoon, and evening every day. Under the section for additional comments was left blank.b. On 12/12/14, at 2:40 p.m., during an interview, Resident 4 stated that there was an incident with Resident 1, who was smoking while the oxygen was on. Resident 4 stated Resident 1 burned his face and after that, the staff took his cigarettes and lighter. Resident 4 stated prior to Resident 1's burn incident he kept his own cigarettes and lighter and used to smoke whenever he wanted but now, he had to follow the facility's smoke break schedule. Resident 4 stated he smoked one pack of cigarettes a day by smoking several cigarettes at a time. A review Resident 4's Admission Record (Face sheet), indicated the resident was admitted to the facility initially on 7/5/12 and last readmitted on 8/6/13. Resident 4's diagnoses included diabetes mellitus (high blood sugars) and schizophrenia (a mental or brain disorder).A review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/23/14, indicated the resident was alert and had the ability to recall. A review of Resident 4's smoking care plan, initially dated 6/23/13, was canceled and updated on 12/2014. The facility's smoking policy was also included in the resident?s smoking assessment dated 12/12/14.c. At 3 p.m., on 12/12/14, Resident 5 was interviewed regarding the facility's smoking policy and procedure. Resident 5 stated the facility's staff explained the smoking safety to him that day (12/12/14) due to Resident 1's burn accident. Resident 5 stated in the past, he had his lighter and cigarettes and whenever he wanted to smoke and would just pull a chair to the corner of the patio and smoke unsupervised. A review of Resident 5's Admission Record indicated the resident was admitted to the facility on 8/26/14. Resident 5's diagnoses included diabetes mellitus (high blood sugar). A review of Resident 5's MDS, dated 10/10/14, indicated the resident was alert and had the ability to recall. A review of Resident 5's care plan for smoking and smoking assessment indicated it was not updated and revised to include the facility's policy until after the smoking incident with Resident 1.On 12/12/14, at 3:30 p.m., during an interview, the DON stated upon a resident's admission, the admitting nurse should conduct a smoking assessment with all new residents. The DON stated the admitting nurse should then initiate a smoking care plan, and explain the facility's smoking policy, which included no smoking material at the residents? bedside and supervision required for the residents who smoked.On 12/12/14, at 4:20 p.m., during an interview, the activity director (AD), stated under no circumstances, will the residents be allowed to keep cigarettes or lighters with them. The AD stated that the DON keeps the residents' cigarettes and lighters. The AD stated prior to the smoking accident, the charge nurses kept the cigarettes and lighters in the medication cart, which was contrary to what Residents 4 and 5 stated.An article by the National Fire Protection Association (NFPA) titled, "Fires and Burns Involving Home Medical Oxygen," dated August 2008, indicated oxygen was one of three parts of the fire triangle. A heat source and fuel (something that can burn) are also required. Oxygen itself is not flammable, but the heat triggers a chemical reaction between the oxygen and fuel molecules. An increased oxygen makes more oxygen available for the chemical reaction, meaning that any fire that occurs will burn faster and hotter. Increased oxygen also lowers the temperature at which things will ignite, including hair, clothing, plastic, skin oils, furniture, etc. Because oxygen is colorless and odorless, elevated levels are not detectable by human senses, which is why patient education is imperative. In 2011, U.S. fire departments responded to an estimated 90,000 smoking-material fires in the U.S., with an estimated 540 civilian deaths.A review of the facility's policy and procedure, with a revised date of 3/2008, and titled, "Smoking Policy," indicated no lighting materials (matches and lighters), tobacco products, or smoking devices would not be allowed in the possession of the residents. The policy further stipulated, upon a resident's admission (7-10 days), residents who desire to smoke will be assessed as well as their ability to do so safely. All new admissions will be on supervised smoking until the assessment was reviewed by the interdisciplinary (IDT) team. Then it would be determine if the resident would be allowed to smoke either under supervision or independently with or without any protective devices. In either case, the policy stipulated that no lighting materials, tobacco products, or smoking devices would allowed in the possession of the resident. The policy further indicated smoking materials will be retained by nursing staff and the resident may come and request for one or two cigarettes at a time they desire to go out to smoke. The facility failed to ensure the residents environment remains as free from accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents, including but not limited to: 1. Failure to follow its policy and procedure regarding smoking. 2. Failure to provide smoking safety education to family members and Residents 1, 4, and 5, who smoked, especially regarding smoking and oxygen usage. 3. Failure to ensure residents did not have smoking materials at the bedside.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. |
| 940000094 |
RIO HONDO SUBACUTE & NURSING CENTER |
940011998 |
A |
04-Feb-16 |
RMRM11 |
24018 |
F329 ?483.25(I) (1)(i-vi) Unnecessary Drugs Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. The facility failed to ensure that each resident?s drug regimen is free from unnecessary drugs, including but not limited to: 1. Failure to ensure medications administered to Resident 12 had adequate monitoring. 2. Failure to ensure medications were not given in the presence of adverse consequences, which indicated the dose should be reduced or discontinued.1a. Resident 12, a 69 year-old female, who had both kidney and liver failure, was receiving an unnecessary drug in the presence of adverse consequences. Resident 12 had a physician's order to receive potassium chloride (KCL), extended release (ER), 20 milliequivalent (mEq) by mouth daily, since 10/16/15, and then for 14 days (11/23/15 through 12/6/15), after a high level of potassium (K+) was identified in the blood at 5.6 (normal reference range [NRR] is between 3.5-5.1 mEq/L [milliequivalent per liter]). On 12/7/15, Resident 12 had an altered level of consciousness (ALOC), and the laboratory results indicated an increased K+ level of 7.0 (hyperkalemia [high K+ levels]).This deficient practice resulted in Resident 12 receiving KCL without an indication for its use, in the presence of adverse consequences, requiring Resident 12 to transfer to urgent care on 12/7/15, for the elevated potassium level. This put Resident 12 at high risk for serious medical complications and death. Resident 12 required fluid via intravenous ([IV] into the vein) and medications to decrease the high levels of K+ while at the urgent care hospital.1b. Resident 12, had a physician's order to receive a laxative (Senokot), twice a day, since 10/16/15, held if the resident had loose stool. Resident 12 continued to receive the laxative twice a day, over two months, with documentation indicating the resident had loose stools for five days, resulting in skin excoriation (scratch or abrasion of the skin) and a Stage II pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). The laxative was not held until 12/18/15, when the survey team questioned the staff about the continued use in the presence of adverse reaction. This deficient practice, of not following the physician's order, resulted in an unnecessary drug in the presence of adverse consequences for Resident 12, who had a 10 pound body weight loss in a month, developed skin excoriations, and a Stage II pressure ulcer (the outer layer of skin and part of the underlying layer of skin is damaged or removed and the wound appearing pink or red) that required a wound care treatment.1a. A review of Resident 12's Face Sheet indicated the resident was re-admitted to the facility on 11/12/15. Resident 12's diagnoses included end stage renal disease ([ESRD] last stage of chronic kidney disease, when the kidneys permanently fail to function), hypertension (elevated blood pressure), epilepsy (a disorder in which a nerve cell activity in the brain is disturbed, causing uncontrolled electrical activity in the brain), hepatic failure (loss of liver function), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow).A review of Resident 12's significant change, in the Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 11/19/15, indicated the resident had limited ability to express needs and understand verbal content. According to the MDS, Resident 12 had short and long-term memory problems, was moderately impaired in cognitive skills for daily decision-making, and required extensive assistance (resident was involved in activity, but staff provided weight-bearing support) for most activities of daily living ([ADL] dressing, toilet use, personal hygiene, and transferring from one area to another).A review of the physician's order, dated 10/16/15, indicated to administer 20 mEq KCL daily, to Resident 12 as a supplement. A review of a laboratory report ([BMP] basic metabolic panel test), dated 11/23/15, indicated Resident 12 had an elevated potassium level of 5.6. A handwritten note of "BMP [laboratory test that included potassium level] and MD notified," was documented on the laboratory report, without a date and a time.A review of Resident 12's Medication Administration Records (MARs) indicated Resident 12 continued to receive potassium chloride (KCL), extended release (ER), 20 mEq by mouth daily, from 11/23/15 to 12/6/15. Resident 12 received a total of 280 mEq of KCL supplement, after Resident 12's K+ was identified to be elevated on 11/23/15. A review of the physician's order, dated 11/23/15, indicated an order to repeat Resident 12's BMP on 12/7/15. There was no documented evidence that KCL was held or discontinued, or that the resident was monitored for physical signs and symptoms of hyperkalemia (high potassium levels), during the 14-day period from 11/23/15 through 12/6/15.A review of the BMP result, prescribed by the physician, dated 12/7/15, indicated Resident 12's potassium level increased to 7.0 mEq/L.A review of the physician's order, dated 12/7/15, indicated an order to transfer Resident 12 to an Urgent Care, due to Resident 12's elevated potassium.A review of an ambulance service report ([BLS] basic life support), dated 12/7/15, indicated Resident 12's vital signs as following: blood pressure of 90/54 (NRR=120/80), heart rate of 84 (NRR= 60-100), respiratory rate at 20 (NRR =16-20), and pain assessment at 0/10 (0=no pain and 10=being the worst). According to the BLS report, Resident 12 was lethargic (drowsy; sluggish), with an altered level of consciousness (ALOC).A review of the urgent care record indicated Resident 12 presented with a diagnosis of hyperkalemia. According to the record, Resident 12 arrived with "eyes closed and lethargic, but responded to yes/no questions." Resident 12 received an IV infusion of sodium chloride 0.9% (salt water similar to body concentration) and received 30 grams of Kayexalate (a medication that helps remove excess K+ from the body) orally. Another BMP level was drawn at the urgent care, resulting in a decreased level in K+ of 6.6 mEq/L. On the same day (12/7/15), Resident 12 transferred back to the skilled nursing facility (SNF). A review of Resident 12's progress note and care plan meeting, dated 11/23/15, and timed at 12:05 p.m., indicated the facility's Interdisciplinary Team (IDT) discussed and documented care of Resident 12's overall condition. However, there was no documented evidence to indicate the resident's elevated K+ level at 5.6 mEq/L, was included in the care plan meeting. There was also no indication if the physician was notified of Resident 12 continuing to receive a KCL supplement daily, with an elevated K+ level, in addition to having diagnoses of kidney and liver failure. On 12/22/15, at 12:20 p.m., during an interview, the directors of staff development (DSD) stated if a resident's laboratory results were abnormal, the nurse should notify the physician immediately and compare it to previous labs to identify what was normal and abnormal. The DSD was asked what the licensed nurse?s responsibility was if a resident's K+ level was elevated. The DSD stated if she was the licensed nurse taking care of that resident, she would assess the resident's vital signs, neurological check (assessment of the sensory motor responses, to determine whether the nervous system was impaired), assess for heart rhythm, and notify the physician. The DSD further stated if the resident's K+ was elevated and the resident was still receiving KCL supplements, she would question the physician to clarify why the resident still received KCL supplements with an elevated potassium level. The DSD also stated she would document everything discussed with the physician. On 12/22/15, at 12:35 p.m., during a telephone interview, a licensed vocational nurse (LVN 13) stated she was Resident 12's nurse on 11/23/15, during the 7 a.m. to 3 p.m. shift. LVN 13 stated she notified Resident 12's physician of all the abnormal results on the BMP, dated 11/23/15. LVN 13 further stated that usually when the licensed nurses notify physicians of abnormal laboratory results, the physicians would ask what medications the resident was receiving. However, LVN 13 could not recall if she had documented the information discussed with the physician during that time, but stated it should be in the clinical records. LVN 13 was asked about Resident 12's condition during the time the resident's K+ was elevated to 7.0. LVN 13 stated Resident 12 was responsive, but restless and more confused than the resident's usual behavior and cognitive level.A review of Resident 12's care plans indicated there was no plan of care developed for Resident 12's elevated K+ level on 11/23/15.A review of the Skilled Nursing PPS Note, for 11/23/15, indicated there was no documentation regarding Resident 12's elevated K+, including the information discussed with the physician, as stated by LVN 13.On 12/22/15, at 1:30 p.m., during a telephone interview with a physician (MD1), he stated he recently took over the care of Resident 12 on 12/6/15. MD1 stated he remembered receiving a telephone call about Resident 12's abnormally high K+ levels on 12/7/15. MD1 stated he ordered for Resident 12 to transfer to urgent care. MD1 was asked what a physician would order if a resident's K+ level was elevated at 5.6 mEq/L. MD1 stated he would order a repeated K+ level right away to monitor the resident. MD1 was asked if he was aware that Resident 12 was receiving KCL supplements of 20 meq daily, while the K+ was elevated. MD1 stated, "Oh really, then definitely I will discontinue the KCL." MD1 reiterated that a physician's response also depended on the information communicated to them by the nurse. MD1 stated it was important for the physician to receive the complete information regarding a resident, because they do not see residents every day.At 2:30 p.m., on 12/22/15, during a telephone interview, the facility?s on-call consultant pharmacist stated the licensed nurse should have clarified the potassium order with the physician. The licensed nurse should have asked the physician if the resident should continue to receive the potassium with the high levels of potassium in Resident 1?s blood.On 12/22/15, at 2:40 p.m., during an interview, the facility's registered dietician (RD) stated if she assessed a resident who had an elevated K+, she would recommend a reduction in KCL intake and refer to the physician to prescribe Kayexalate. The RD stated she was aware that Resident 12 had renal insufficiency, but did not include that diagnosis in her previous progress note. The RD stated she usually writes the laboratory values in her notes when the value is abnormal.The RD stated if she did not recommend the laboratory work, she "usually" does not follow-up on the laboratory results.A review of a Nutrition Progress Note, written by the RD, dated 12/11/15, indicated the RD documented Resident 12 was receiving KCL. The RD included Resident 12's labs from 11/19/15, but the RD did not note Resident 12's recent labs from 11/23/15 and 12/7/15, which included the resident's elevated K+. A review of the licensed nurse's Daily and Q Shift (every shift) Charting, dated 12/7/15, and timed at 9:35 p.m., indicated Resident 12 returned to the facility from the urgent care with a K+ level decreased to 6.6.A review of Resident 12's care plans indicated no plan of care was developed regarding Resident 12's elevated K+ levels of 6.6, after Resident 12 returned to the facility from the urgent care.During an interview with the assistant nursing director (ADON), on 12/22/15, at 2:35 p.m., she acknowledged that there was no other documented evidence in Resident 12's clinical record that a care plan was developed and the facility monitored the resident for signs and symptoms of hyperkalemia when it was discovered on 11/23/15, and when resident returned to the facility from urgent care on 12/7/15.A review of the facility's policy and procedures, with a revision date of 11/2005, titled, "Physician Notification of Change Resident Condition," indicated that staff should notify the physician when there is a need to alter the resident's treatments significantly. Before notifying the physician, the licensed nurse must observe and assess the overall condition utilizing physical assessment and chart review. The policy also stipulated that notification to the physician includes a summary of the condition change and an assessment of the resident's vital signs and system review, focusing on the condition and/or signs and symptoms for which the notification is required, and to document in the resident's medical record.A review of an online reference from Omnicare Pharmacy, provided by the facility titled, "Omniview-Drug Information for Potassium Chloride 10% liquid," printed on 12/22/2015, at 3:40 p.m., indicated the side effects of potassium included upset stomach, nausea, vomiting, gas, or diarrhea. The article indicated if too much K+ was in the blood, it could cause serious side effects. Symptoms of overdose may include muscle weakness and confusion. The KCL reference further indicated that precautions were necessary when taking potassium, especially with residents who have a medical history of heart and kidney problems. "Caution is advised if you have diabetes, liver disease, or any other condition that requires you to limit/avoid these substances in your diet." A review of an online article, titled, "End-Stage Renal Disease: Nutritional Considerations," indicated unhealthy kidneys cannot tolerate a high K+ diet because the kidneys are unable to excrete the K+. This causes an increase of K+ in the blood that can result in life-threatening medical conditions, such as hyperkalemia-induced arrhythmia (an irregular beating of the heart caused by elevated potassium levels in the blood). 1b. A review of Resident 12's Admission Face Sheet indicated the resident was re-admitted to the facility on 11/12/15. Resident 12's diagnoses included end stage renal disease ([ESRD] the last stage of chronic kidney disease, when the kidneys permanently fail to function), but was not receiving dialysis treatments (a machine used to filtered the blood), hypertension (elevated blood pressure), Type 2 diabetes mellitus (a chronic disease in which the blood sugar "glucose" levels are abnormally high in the blood), colitis (an inflammatory reaction in the colon), hepatic failure (loss of liver function), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). A review of Resident 12's significant change in the MDS, dated 11/19/15, indicated the resident had limited ability to express needs and understand verbal content. According to the MDS, Resident 12 had short and long-term memory problems, was moderately impaired in cognitive skills for daily decision-making and required extensive assistance (resident was involved in activity, but staff provided weight-bearing support) for most ADLs. Resident 12 required assistance of a one-person physical assist for ADLs. The MDS indicated the resident was always incontinent (inability to control) of bladder and frequently incontinent of bowel, but did not participate in a toileting program. The MDS indicated Resident 12 had a Stage II pressure ulcer and was at risk of developing pressure ulcers. The treatments listed on the MDS included pressure-reducing device for the bed, pressure ulcer care, and the application of ointments and medications. A review of Resident 12's History and Physical (H/P) Examination, dated 11/13/15, indicated the resident had a diagnosis of cholangiocarcinoma (a cancer in the slender tubes of the body that carry the digestive fluid bile through the liver), and two biliary drains (drainage tubes inserted through the skin into one of the bile ducts in the liver when blocked, to allow digestion of fats to drain). According to the H/P, Resident 12 did not have the capacity to understand and make decisions, generally appeared sleepy, but can be aroused, and had bilateral lower extremity weakness. A review of Resident 12's physician's order, dated 11/12/15, indicated to administer Senokot 8.6 mg tablet PO (by mouth) twice a day as a stool softener, to Resident 12 and to hold for loose stool. A review of DailyMed, an online drug reference, indicated Senokot was a laxative, and not a stool softener, used to relieve constipation. The article indicated Senokot should not be used longer than one week, unless directed by a physician. A review of the progress notes from the RD, dated 12/11/15, indicated Resident 12 lost 10 pounds in one month at 7.5% of body weight.Resident 12, who was incontinent of bowel and bladder, and assessed as at risk for developing pressure sores, had loose and watery stools for five (5) days. The licensed nurse did not re-assess the resident for increased risk for skin breakdown, after the resident's change of condition of watery stools, and did not hold the laxative (Senokot) as ordered by the physician, if the resident had loose stool. On 12/17/15, the night shift (11 p.m. -7 a.m.) certified nursing assistant (CNA) did not document the consistency of Resident 12's stool on the ADL tracking record.On 12/18/15, at 7 a.m., Resident 12 was observed with her eyes closed, lying in a supine position in bed with the privacy curtains completely closed. The bottom half of Resident 12's dress and both of her hands were soiled with watery stool. Resident 12 was observed touching the wet stool on the front lower half of her dress with her fingers, with her eyes closed. At 7:25 a.m., on 12/18/15, during an ADL care observation, CNA 1 was observed cleaning Resident 12. Resident 12's sacrum (a triangular-shaped bone consisting of five segments), and left and right upper buttocks were observed red with two, circular, opened areas on Resident 12's left buttocks. Resident 12 had a large amount of watery, dark brown colored stool on the buttocks and the perineal area (a diamond-shaped area that included the genital area and the anus). Resident 12 required extensive assistance from CNA 1 for positioning during care.Treatment Nurse 1 (TN1) received a telephone physician's order, dated 12/18/15, and timed at 9 a.m., to treat Resident 12's pressure ulcer, which included to cleanse the wound with normal saline, pat dry, and apply Duoderm (a form of dressing called [hydrocolloid dressing] used on a variety of wounds and skin conditions, it contains a gel-forming agent).On 12/18/15, at 9:40 a.m., during a treatment observation, of Resident 12's pressure ulcer with TN 1, a small amount of watery stool was observed on Resident 12's perineal and buttocks area. Resident 12 was observed drowsy with eyes closed, and did not respond to her name when called twice. TN 1 stated the resident had a Stage II pressure sore to sacro-coccygeal area ([sic] which was actually on the resident's left buttocks) that measured 0.5 centimeter (cm) by 0.5 cm.On 12/18/15, at 2:30 p.m., during an interview, CNA 1 stated, "I let the charge nurse, (LVN 3) know that her (Resident 12) poop was watery." CNA 1 stated Resident 12 had a large, watery bowel movement (BM) on the morning of 12/18/15, and then a smaller BM at approximately 11:40 a.m. CNA 1 stated she had been taking care of Resident 12 since 12/16/15, and stated she documented, during her shift, "SL" (soft/loose) as the resident's stool consistency since 12/16/15, under "Bowel" category on the ADL Tracking Record. She stated the CNA who worked the night prior (12/17/15) informed her that Resident 12 had loose stool two times during the night shift. However, CNA 1 stated the night shift CNA did not document Resident 12's loose BM for the night shift on 12/17/15.During an interview, on 12/18/15, at 2:45 p.m., with LVN 5 (assigned nurse of Resident 12 for 12/18/15, 7-3 p.m. day shift) and LVN 3 (assigned charge nurse for 12/18/15), LVN 5 stated when she arrived in the morning to start her shift; Resident 12 had a soft stool. LVN 5 stated, "I know it (stool) wasn't formed, but I didn't know it was wet." LVN 5 stated, "Typically, when a CNA says the bowel movement is loose, we hold the medicine and call the doctor." The December 2015 medication reconciliation record (MAR) was shown to LVNs 3 and 5, which indicated to hold Senokot when Resident 12's stool was loose. LVN 5 stated and verified she administered Senokot to Resident 12, on 12/18/15 at 9 a.m., although the resident was having loose watery stools. LVN 3 stated, "I go by the CNAs, in telling me about the stool because they know better." LVN 3 stated that CNA 1 informed her of Resident 12's loose BM that morning. LVN 3 stated she notified LVN 5, but stated LVN 5 might have forgotten and administered the Senokot anyway. LVN 5 denied receiving this information, which resulted in LVN 5 continuing to administer the morning dose of laxative to Resident 12 for that day.A review of Resident 12's ADL Tracking Record indicated Resident 12 was incontinent with soft/loose stools on the following dates/shifts on 12/14/15, twice during the day shift (7 a.m.-3 p.m.); 12/15/15, three times during the day shift (7 a.m. - 3 p.m.), and two extra-large stool during the night shift; 12/16/15, one small soft/loose stool during the day shift and one large loose stool during the night shift; 12/17/15, one medium loose stool during the day shift; 12/18/15, two large soft/loose stools during the day shift; 12/19/15, two medium size soft/loose stools during the day shift; 12/20/15, two soft/loose stools during the day shift and 12/21/15, one medium soft/loose stool during the night shift.A review of Resident 12's Medication Administration Record (MAR), dated 12/14/15 through 12/18/15, indicated Resident 12 received Senokot 8.6 milligram (mg) tablet twice a day. According to the MAR, ADL tracking, and interviews, the licensed nurses did not hold the Senokot as ordered by the physician, during the five days Resident 12 was having loose bowel movements, from 12/14/18 through 12/18/15, which resulted in skin excoriation, Stage II pressure sore. A review of an online drug reference, titled, "Omni view-Drug Information," (for Senna [brand name for Senokot]) 8.6 MG soft gel, provided by the director of nursing (DON), with a print date of 12/22/15, and timed at 3:38 p.m., indicated Senokot was known as a stimulant laxative, used to treat constipation. The side effects of the medication included nausea, diarrhea (loose watery stools), weakness, and mental/mood changes (confusion). The drug information stated if any of the side effects persisted, to notify the physician or pharmacist promptly. The facility failed to ensure that each resident?s drug regimen is free from unnecessary drugs, including but not limited to: 1. Failure to ensure medications administered to Resident 12 had adequate monitoring. 2. Failure to ensure medications were not given in the presence of adverse consequences, which indicated the dose should be reduced or discontinued.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. |
| 940000094 |
RIO HONDO SUBACUTE & NURSING CENTER |
940011999 |
A |
04-Feb-16 |
RMRM11 |
22829 |
F 314 ?483.25(c)(1-2) Pressure Sores Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. F309 ?483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.The facility failed to provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and to ensure that a resident who enters the facility without pressure sores does not develop pressure sores; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing, including but not limited to:1. Failure to Identify Resident 12?s newly developed pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). 2. Failure to accurately assess Resident 12's risk for pressure ulcer development, during a change of condition. 3. Failure to implement the facility?s policy, dated 8/31/11 and titled, ?Pressure Ulcer Prevention and Management,? and Resident 12's plan of care for the use of pressure relieving devices for high-risk residents. 4. Failure to follow the physician's orders to withhold a laxative (Senokot) when Resident 12 was having loose and watery stools. 5. Failure to implement interventions to manage the complications of Resident 12 having loose and watery stools.Resident 12, who was incontinent (inability to control) of bowel and bladder (B/B), had low protein levels, and was assessed as a high-risk for developing pressure ulcers had loose and watery stools for five (5) days. The licensed nurse did not re-assess the resident for increased risk of skin breakdown, after the resident had a change in condition and had watery loose stools, but did not hold the laxative (Senokot) as ordered by the physician. The facility also failed to implement interventions to manage the complications of Resident 12 having loose and watery stools to prevent skin breakdown, especially on the areas of the body, such as the sacrococcygeal (pertaining to the sacrum and coccyx part of the body [triangular area]). On 12/17/15, the night shift (11 p.m. -7 a.m.) certified nursing assistant (CNA 1) did not document the consistency of Resident 12's stool on the ADL (activities of daily living) tracking record. On 12/18/15, CNA 1 informed a licensed vocational nurse (LVN 3), who informed the assigned charge nurse, LVN 5, that Resident 12 was having loose stools. LVN 5 denied receiving this information, which resulted in LVN 5 continuing to administer the laxative.As a result of this deficient practice, Resident 12 developed a skin breakdown on the left buttocks, which the facility failed to identify and assess. The opened wounds was later identified as a Stage II pressure ulcer (the outer layer of skin and part of the underlying layer of skin is damaged or removed and the wound appearing pink or red) during an ADL care observation. The Stage II pressure ulcer required wound care and treatment every three days. On 12/17/15, at 9 a.m., during a room observation, Resident 12 was observed lying on her back (supine position) in bed. At 2:15 p.m., on 12/17/15, Resident 12 remained lying in a supine position in the bed, not repositioned. On 12/18/15, at 7 a.m., Resident 12 was observed with her eyes closed while lying in a supine position in bed with the privacy curtains completely closed. The front bottom half of Resident 12's dress and both of her hands were soiled with brown colored watery stool. Resident 12 was observed touching the wet stool on the front lower half of her dress, while her eyes were closed. At 7:25 a.m., on 12/18/15, during an ADL care observation, CNA 1 was observed cleaning Resident 12. Resident 12's sacrum (a triangular-shaped bone in the lower back and consists of five segments), left and right upper buttocks were observed red with two circular opened areas on Resident 12's left buttocks. Resident 12 had a large amount of watery, dark brown colored stool on the buttocks and the perineal area (the genital area between the lower end of the vagina and anus in females, and the scrotum and anus in males). Resident 12 required extensive assistance from CNA 1 for positioning during care.A record review of a physician's telephone order, dated 12/18/15, and timed at 9 a.m., indicated Treatment nurse (TN 1) received orders to treat Resident 12's pressure ulcer, which indicated, ?sacrococcygeal pressure ulcer, cleanse with normal saline, pat dry, and apply Duoderm (a form of dressing called [hydrocolloid dressing] used on a variety of wounds and skin conditions, containing a gel-forming agent)?.During an interview on 12/18/15, at 9:28 a.m., TN 1 stated she was just informed by CNA 1 that Resident 12 had a pressure ulcer on the sacrum. TN 1 stated she had never noticed it before and was not sure if Resident 12 was admitted with the pressure ulcer.A review of the physician's progress note, dated 11/16/15, and timed at 2:30 p.m., indicated Resident 12 had mild redness in the inguinal ([groin] located on the lower portion of the anterior abdominal wall) and buttocks area. On 12/18/15, at 9:40 a.m., during a treatment observation of Resident 12's pressure ulcer, with TN 1, a small amount of watery stool was observed on Resident 12's perineal and buttocks area. Resident 12 was observed drowsy with eyes closed and did not respond to her name when called twice. TN 1 stated the resident had a Stage II pressure sore to sacro-coccygeal area ([sic] which was actually on the resident?s left buttocks) that measured 0.5 centimeter (cm) x 0.5 cm. On 12/18/15, at 2:30 p.m., during an interview, CNA 1 stated, "I let the charge nurse (LVN 3) know that her (Resident 12) poop was watery." CNA 1 stated Resident 12 had a large, watery BM on the morning of 12/18/15, and then a smaller BM at approximately 11:40 a.m. CNA 1 stated she had been taking care of Resident 12 since 12/16/15, and stated she documented, during her shift, "SL" (soft/loose) as the resident's stool consistency since 12/16/15, under "Bowel" category on the ADL (Activities of Daily Living) Tracking Record. CNA1 stated the CNA who worked the night prior (12/17/15) informed her that Resident 12 had loose stool two times during the night shift. However, CNA 1 stated the night shift CNA did not document Resident 12's BM for the night shift on 12/17/15.During an interview, on 12/18/15, at 2:45 p.m., with LVN 5 (Resident 12's assigned nurse on 12/18/15), and LVN 3 (Resident 12's assigned nurse on 12/17-12/18/15), LVN 5 stated when she arrived in the morning to start her shift and was informed Resident 12 had a soft stool. LVN 5 stated, "I know it wasn't formed, but I didn't know it was wet." LVN 5 stated, "Typically, when a CNA says the bowel movement was loose, we hold the medicine and call the doctor." The MARs for 12/2015 was shown to LVNs 3 and 5, which indicated to hold Senokot when Resident 12's stool was loose. LVN 5 stated and verified she administered Senokot to Resident 12 on 12/18/15 at 9 a.m., although the resident was having loose watery stools. LVN 3 stated, "I go by the CNAs, in telling me about the stool because they know better." LVN 3 stated CNA 1 informed her of Resident 12's loose BM that morning and she stated she notified LVN 5, but stated LVN 5 might have forgotten and administered the Senokot anyway.A review of Resident 12's Admission Face Sheet indicated the resident was a 69-year-old female, re-admitted to the facility on 11/12/15. Resident 12's diagnoses included end stage renal disease ([ESRD] the last stage of chronic kidney disease, when the kidneys permanently fail to function), hypertension (a condition in which the blood pressure is elevated), Type 2 diabetes mellitus (a chronic disease in which the blood sugar "glucose" levels are abnormally high in the blood), colitis (an inflammatory reaction in the colon), hepatic failure (loss of liver function), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow).A review of Resident 12's History and Physical (H/P) Examination, dated 11/13/15, indicated the resident had a diagnosis of cholangiocarcinoma (a cancer in the slender tubes of the body that carry the digestive fluid bile through the liver), and two biliary drains (drainage tubes inserted through the skin into one of the bile ducts in the liver when blocked, to allow digestion of fats to drain). According to the H/P, Resident 12 did not have the capacity to understand and make decisions, generally appeared sleepy, but can be aroused, and had bilateral lower extremity weakness. A review of Resident 12's Bowel and Bladder Assessment, dated 11/12/15, upon Resident 12's readmission, indicated Resident 12 had a total score of 15 (score of 15-21=good candidate for training). However, the assessment indicated Resident 12 had control of both B/B without any incontinence, which was contrary to the resident's MDS assessment.During a concurrent interview and record review, on 12/18/15, at 3:10 p.m., a registered nurse supervisor (RN 1) stated Resident 12's B/B Assessment, dated 11/12/15, did not correspond to the resident's current health condition. RN 1 stated the admission charge nurse was responsible for completing the B/B Assessment. RN 1 stated Resident 12 was incontinent and the B/B assessment would be corrected. A review of Resident 12's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 10/23/15, indicated Resident 12 expressed needs and wants, and understood verbal content. The MDS indicated Resident 12 had a score of 10, for the cognitive brief interview for mental status (BIMS), indicating the resident was interview-able. According to the MDS, Resident 12 required total assistance (full staff performance every time during a 7-day period), with a one-person physical assist for activities of daily living (ADLs) such as, dressing, toilet use, personal hygiene, and transferring from one area to another. The MDS indicated the resident was always incontinent of bladder and frequently incontinent of bowel, but did not participate in a toileting program. The MDS indicated Resident 12 had a Stage II pressure ulcer and was at risk of developing pressure ulcers. The documented treatments that were provided included pressure-reducing device for the bed, pressure ulcer care, and the application of ointments and medications.During a concurrent interview and observation, at 3:30 p.m., on 12/18/15, while at Resident 12's bedside, TN 1 verified Resident 12's mattress was a regular, standard mattress, and it did not provide pressure relief. A review of Resident 12's basic metabolic panel ([BMP] a chemistry blood test), dated 11/16/15, indicated Resident 12's albumin was low at 1.8 (normal reference range [NRR] is 3.5-5.7 gram per deciliter [g/dl]) and total protein level was low at 5.0 g/dl (NRR 6.4-8.9).According to the National Pressure Ulcer Advisory Panel (NPUAP), low serum albumin and protein puts residents at a higher risk of developing pressure ulcers. Poor nutritional status was a contributing factor in pressure ulcer development and impaired wound healing. The facility failed to address this as a risk for Resident 12 to develop pressure ulcers. A review of the Licensed Nurses Weekly Summary, dated 11/24/15, during the 7-3 p.m. shift, indicated Resident 12 was bed bound (spends most of the time in bed), and required total assistance with activities of daily living "ADL" (eating, toilet use, dressing, walking, bathing, personal hygiene, transferring, and repositioning in bed). The weekly summary for Resident 12's decubitus care had not been completed, and indicated "N/A" (not applicable).A review of Resident 12's care plan, initiated on 11/12/15, titled "Actual Skin Breakdown related to Perineal Irritation," did not have documented timeframes for the goal based on the plan of care. The staff's interventions included to monitor the wound every day, provide good perineal/incontinent care and provide wound care treatment as ordered.A review of all of Resident 12's care plans, provided by the director of nursing (DON) on 12/22/15, did not indicate there was a plan of care initiated for Resident 12's ongoing risk for pressure ulcers. A review of Resident 12's significant change in status assessment, MDS, dated 11/19/15, indicated the resident was at risk of developing pressure ulcers. According to the MDS, Resident 12 sometimes expressed needs and wants, and sometimes understood verbal content. Resident 12 was unable to complete the brief interview for mental status (BIMS) and Resident 12 had short and long-term memory problems, with moderately impaired cognitive skills for daily decision-making. According to the MDS, Resident 12 required extensive assistance with ADLs and was always incontinent of B/B and did not participate in a toileting program. A review of Resident 12's ADLs Tracking Record, indicated Resident 12 was incontinent with soft/loose stool on the following dates: 12/14/15, twice (2) during the day shift (7 a.m.-3 p.m.); 12/15/15, three (3) times during the day shift (7 a.m. - 3 p.m.), two (2) extra-large during the night shift; 12/16/15, one (1) small soft/loose stool during the day shift, one (1) large loose stool during the night shift; 12/17/15, one (1) medium loose stool during the day shift; 12/18/15, two (2) large soft/loose stool during the day shift; 12/19/15, two (2) medium soft/loose stool during the day shift; 12/20/15, two (2) soft/loose stool during the day shift and on 12/21/15, one (1) medium soft/loose stool during the night shift.A review of Resident 12's physician's order, originally ordered on 10/16/15 and reordered on 11/12/15, indicated to administer Senokot 8.6 mg tablet PO (by mouth) twice a day as a stool softener, and to hold for loose stool. A review of the DailyMed, an online article, indicated Senokot was a laxative, and not a stool softener, used to relieve constipation. The article also indicated Senokot should not be used longer than one week, unless directed by a physician. A review of Resident 12's Medication Administration Records (MAR), dated 12/14/15 through 12/18/15, indicated Resident 12 received Senokot 8.6 milligram (mg) tablet twice a day. According to the MAR, ADL Tracking Records, and interviews, the licensed nurses did not hold the Senokot as ordered by the physician during the five days Resident 12 was having loose bowel movements from 12/14/18 through 12/18/15. A review of an online drug description, titled, "Omni view-Drug Information," (for Senna [brand name for Senokot]) 8.6 MG soft gel, provided by the DON, with a print date of 12/22/15, and timed at 3:38 p.m., indicated Senokot was known as a stimulant laxative, used to treat constipation, not a stool softener, as indicated on Resident 12?s physician?s orders. The side effects of the medication included nausea, diarrhea (loose watery stools), weakness, and mental/mood changes (confusion). The drug information stated that if any of the side effects persisted, to notify the physician or pharmacist promptly.A review of the Resident 12's Braden Scale (assessment tool for predicting pressure sore risk), from 10/16/15 admission, dated 10/16/15 through 10/30/15, indicated Resident 12 had a score of 9. According to the scale, a total score of nine and below, indicated the resident was at severe risk of developing a pressure ulcer.A review of the Braden Scale, dated 11/12/15 through 12/3/15, indicated Resident 12 had a score of 18, indicating Resident 12 had a mild risk of developing a pressure ulcer, although the resident had developed excoriation and had a history of pressure ulcers. The resident's health condition improved compared to the previous month's Braden Scale, but did not correspond to the MDS, dated 11/19/15, which indicated Resident was at risk for developing pressure ulcers. A review of the Nursing Admission and Assessment, during Resident 12's re-admission on 11/12/15, did not indicate Resident 12 had a pressure ulcer at re-admission. The Nursing Admission and Assessment also indicated Resident 12 was continent (able to control) of bowel and bladder, which was contrary to the MDS assessment. A review of the Braden Scale, dated 12/19/15, indicated Resident 12 had a score of nine, which indicated Resident 12 was at severe risk of developing a pressure ulcer. There was no documented evidence the resident's risk for developing a pressure sore was re-assessed when the resident had loose stools from 12/14/15 to 12/18/15.A review of the facility's policy, dated 8/31/11, and titled, "Pressure Ulcer Prevention and Management Policy," indicated risk factors that increased the resident's susceptibility to develop or prevent pressure ulcers from healing. The risk factors included diabetes, chronic bowel and urinary incontinence, chronic or end stage renal disease, impaired mobility, decreased functional ability, malnutrition (lack of proper nutrition) or hydration deficits, and cognitive impairment. The policy also stipulated that a licensed nurse would complete a skin assessment as well as a risk assessment using a standardized risk assessment tool and develop a care plan to address the resident's risk for skin breakdown.The policy indicated the licensed nurse and dietician would assess the resident's medications and nutritional status if it contributed to the break in skin integrity. For prevention, the facility's policy indicated applying pressure redistribution devices for residents in bed, and to turn and reposition residents if unable to do so independently.The policy indicated preventative measures that might need to be kept in place indefinitely to prevent the risk of the resident's pressure ulcer from reopening. During an interview, on 12/22/15, at 10 a.m., TN 3 stated, she completed the Braden Scale for Resident 12, from 11/12/15 through 12/3/15. TN 3 stated, "Sensory perception" category with a score of four (4) (no impairment) meant the resident was responsive and able to notify the staff when wet, but Resident 12 had recently been too weak. TN 3 stated that Resident 12 was "often moist," but was documented with a score of four (rarely moist). TN 3 stated, "She wears diapers, which means she has no control using the bathroom. I guess I could have changed it to moist." After reviewing both Resident 12's Braden Scales, dated 10/16/15 through 10/30/15 and 11/12/15 through 12/3/15, TN 3 stated the ?sensory perception, moisture, and mobility," scores for Resident 12 were incorrect. TN 3 stated a correct score for Resident 12 was a score of nine or below, which indicated Resident 12 was at severe risk for developing pressure ulcers. TN 3 stated when Resident 12 was admitted to the facility in October, her poor health condition remained unchanged. TN 3 stated that based on her recent observation, Resident 12's health was getting worse and slowly declining. On 12/22/15, at 11:20 a.m., during an interview, the director of staff development (DSD) stated, "You need to consider the co-morbidity (the simultaneous presence of two chronic diseases or conditions in a patient) and overall overview of all shifts to do the Braden Scale Assessment." The DSD stated the content of the Braden Scale, B/B Program Assessment Tool, and Neurological Evaluation Flow Sheet as inaccurate for Resident 12. The DSD stated, the nursing supervisor admitting the resident was responsible for completing the assessments and the charge nurse and treatment nurse needed to assess the resident within two hours of admission. The DSD stated, the director of nurses (DON), assistant director of nurses (ADON), and MDS (Minimum Data Set) Nurse were responsible for educating staff on how to accurately complete the assessment forms.The facility failed to provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and to ensure that a resident who enters the facility without pressure sores does not develop pressure sores; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing, including but not limited to:1. Failure to Identify Resident 12?s newly developed pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). 2. Failure to accurately assess Resident 12's risk for pressure ulcer development, during a change of condition. 3. Failure to implement the facility?s policy, dated 8/31/11 and titled, ?Pressure Ulcer Prevention and Management,? and Resident 12's plan of care for the use of pressure relieving devices for high-risk residents. 4. Failure to follow the physician's orders to withhold a laxative (Senokot) when Resident 12 was having loose and watery stools. 5. Failure to implement interventions to manage the complications of Resident 12 having loose and watery stools.The above violations, jointly, separately, or in any combination presented an imminent danger that death or serious physical harm would result, or a substantial probability that death or serious physical harm would result. |
| 940000014 |
Rose Villa Healthcare Center |
940012489 |
B |
4-Aug-16 |
EI1011 |
5856 |
F225 ? 42 CFR 483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). On 8/7/15 at 9:05 a.m., an investigation of a complaint was conducted at the facility to investigate an allegation of verbal abuse. According to the complaint, the licensed vocational nurse (LVN 1) allegedly informed Resident 1 that she smelled and LVN 1 proceeded to slam the privacy curtain shut. Based on interview and record review, the facility failed to implement its abuse prevention policy and procedure by failing to: 1. Report immediately (as soon as possible but not to exceed 24 hours after discovery of the incident) to the Department (Licensing and Certification Program) an allegation of verbal abuse by LVN 1 to Resident 1. The family member (FM 1) made an allegation of verbal abuse and reported the allegation to the administrator on 7/30/15 that the licensed vocational nurse (LVN 1) was verbally abusive to Resident 1 by saying aloud that the resident smelled and needed to be changed. The administrator did not report the allegation to the Department immediately or within 24 hours of the knowledge of the incident. This deficient practice resulted in Resident 1 feeling humiliated and FM 1 concerned of Resident 1 not receiving safe care and services from the facility staff, which later resulted in FM 1 taking the resident home against medical advice (AMA). A review of Resident 1's Admission Record indicated the resident was admitted to the facility on 7/19/15 with diagnoses that included muscle weakness and aftercare healing from a traumatic fracture to the leg. According to the admission Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 7/24/15, Resident 1 was able to make her needs known and understand others. Resident 1 had no impairments in cognitive skills and required extensive assistance (resident involved in the activity; staff provide weight-bearing support) with one person physical assist in transferring, toileting, and personal hygiene. According to the family member (FM 1), during a telephone interview, on 12/22/15 at 9 a.m., she spoke with the administrator and the director of nursing (DON) on 7/30/15 regarding the incident with Resident 1 hearing LVN 1 stating that the resident smelled. During an interview, on 8/7/15 at 9:30 a.m., the director of nursing (DON) stated that FM 1 met with the administrator and addressed the issue that there could have been a miscommunication between Resident 1 and LVN 1, who was conducting an initial body assessment on the resident. The DON stated that LVN 1 stated there was a strong urine odor in the resident's room. The DON stated FM 1 told the facility staff that Resident 1 would get better care at home and the resident was discharged AMA (Against Medical Advice). During an interview, on 8/7/15 at 10 a.m., LVN 1 stated she went to Resident 1's room to assess the resident's skin and she closed the curtain to provide privacy but because the curtain got stuck on the tracks, she pulled the curtain hard, which made a loud noise. During the interview, LVN 1 stated she had spoken out loud in the room, "How come it smells in here?" and then she asked Resident 1 if she could check the resident. LVN 1 stated she asked the certified nursing assistant (CNA 1) to clean Resident 1 really well. LVN 1 stated she had thought about what she said out loud and thought it might have come out wrong. LVN 1 stated she apologized to the family because she did not mean it. During an interview, on 8/7/15 at 10:10 a.m., CNA 1 stated she was in another resident's room and LVN 1 found her to tell her to clean Resident 1 real good because the resident smelled bad and LVN 1 needed to provide wound treatment care for the resident. During an interview, on 3/10/16 at 2:40 p.m., the administrator stated he was supposed to report all allegations of abuse. The administrator stated he met with Resident 1's family and felt it was a miscommunication between Resident 1 and LVN 1 due to language differences. The administrator stated that the family had understood the situation and agreed it was not abuse, which was why he did not report the incident. During an interview, on 3/10/16 at 3:20 p.m., CNA 3 stated that if a staff member told a resident that he/she smelled, it was considered verbal abuse. During an interview, on 3/10/16 at 3:40 p.m., CNA 4 stated all the different types of abuse and if a facility staff member told a resident he/she smelled, it was considered verbal abuse. CNA 4 also stated it should be reported right away because the facility staff members were all mandated reporters. A review of the facility's undated policy and procedure titled, "Resident Rights - Abuse Prevention," indicated all alleged incidents of abuse, mistreatment or neglect are to be reported to the State Licensing Agency immediately or within 24 hours. All allegations of abuse, mistreatment and neglect are to be reported immediately to the Ombudsman/local law enforcement via phone and follow-up writing. The facility failed to implement its abuse prevention policy and procedure by failing to: 1. Report immediately (as soon as possible but not to exceed 24 hours after discovery of the incident) to the Department (Licensing and Certification Program) an allegation of verbal abuse by LVN 1 to Resident 1. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 940000095 |
RIVIERA HEALTHCARE CENTER |
940012494 |
B |
5-Aug-16 |
36RS11 |
9374 |
?72541. Unusual Occurrences Occurrences such as epidemic outbreaks, poisoning, fires, major accidents, 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. On 8/21/15 at 3:30 p.m., an investigation of a complaint was conducted regarding a possible outbreak of scabies (a contagious, intensely itchy skin condition caused by a tiny, burrowing mite) in the facility that was not reported to the Department. Based on observation, interview, and record review, the facility failed to report an outbreak of scabies to the Department (the Licensing and Certification District Office) within 24 hours. The facility had clinically suspected cases of scabies (Resident 1 and 2) during a two week period of time as of 7/13/15. Also, the facility had two clinically suspected cases of scabies (Resident 3 and 4) during a two week period of time as of 8/20/15. The facility had two opportunities to report an outbreak of scabies to the Department within 24 hours from 7/13/15 and 8/20/15 but failed to do so. These deficient practices had the potential to spread this contagious condition to other residents. a. A review of Resident 1's admission face sheet indicated the resident was admitted on 12/19/14 with diagnoses that included urinary tract infection (UTI, an infection of the kidneys), failure to thrive (FTT, describes a state of decline that is many factors and may be caused by chronic concurrent diseases and functional impairments), and spinal stenosis (it is the narrowing of spaces in the backbone which causes pressure on the spinal cord and nerves). A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/23/15, indicated the resident was able to make her needs known and was able to understand others, had minimal impairment in cognitive skills, and required extensive assistance (staff provided weight-bearing support) from staff in activities of daily living (ADLs). According to the dermatology (a branch of medicine dealing with skin diseases) consult, dated 6/30/15, Resident 1 was evaluated for itchy rash on the right chest area, axilla (underarm), and inner arm. The dermatologist conducted a follow-up evaluation on 7/13/15 and ordered an Elimite cream (a medication used to treat scabies) application for Resident 1 for prophylaxis (preventive measure). Resident 1?s Treatment Record for July 2015 indicated she received an Elimite cream treatment on 7/14/15 and 7/21/15. A review of Resident 2's admission face sheet, indicated the resident was admitted on 1/20/15, with diagnoses that included aftercare for pathological hip fracture (a bone broken, not by trauma alone, but so weakened by disease as to break with abnormal ease) and osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down) of the lower legs. A review of Resident 2's MDS, dated 7/26/15, indicated the resident was able to make her needs known and was able to understand others, had minimal impairment in cognitive skills, and required total dependence (full staff performance every time) from staff in ADLs. According to the physician?s progress notes, dated 7/6/15, Resident 2 had dermatitis (an inflammation of the skin) on her back, arms, and neck. The physician ordered for the resident to receive five (5) tablets of the 3 milligrams (mg) Ivermectin (a medication used to treat scabies) one time now and repeat in one week, wash her bedding in hot water, and to use scabies precautions when providing care to the resident. Resident 2?s PRN (as needed) Medication (a medication administration for as needed medications) for July 2015 indicated the resident received five (5) tablets by mouth of the 3 mg Ivermectin on 7/7/15 and 7/14/15. On 10/21/15 at 4:15 p.m., Resident 1's clinical record was reviewed with the director of nursing (DON). The DON stated, during an interview, Resident 1's Treatment Record for July 2015 indicated the resident had a physician order to receive an Elimite cream on 7/13/15 and the order was carried out (the medication was given) by the licensed vocational nurse (LVN 2) on 7/14/15 during the 3-11 p.m. shift. On 10/21/15 at 4:20 p.m., Resident 2's clinical record was reviewed with the DON. The DON stated, during an interview, Resident 2's PRN Medication record for July 2015 indicated the resident had a physician order on 7/6/15 to take 5 tablets orally of Ivermectin 3 milligram(mg) QD (once a day) x1 now (one time now) and repeat in one week. The DON stated the PRN Medication record indicated that Resident 2 received the medication on 7/7/15 at 9 a.m. and again on 7/14/15 at 9 a.m. During the interview, when asked what the Elimite and Ivermectin were used for, the DON stated that both medications were used to treat scabies. The DON stated the two clinically suspicions cases of scabies with Resident 1 and 2 should have been first reported to the Department in July 2015 based on the definition of an outbreak of scabies on the "Management of Scabies Outbreaks in California Health Care Facilities." A review of the facility's adopted guidelines titled, "Management of Scabies Outbreaks in California Health Care Facilities," dated 3/2008, indicated the primary goal of an outbreak investigation is to identify risk factors contributing to the outbreak and to take corrective action to prevent further transmission of scabies cases. The definition of an "outbreak of scabies" may include: a. Two or more confirmed (positive skin scraping) cases of scabies identified in patients, healthcare workers, volunteers and/or visitors during a two week period of time, or b. One confirmed (positive skin scraping) and at least two clinically suspect cases identified in patients, healthcare workers, volunteers and/or visitors during a two week period of time, or c. At least two clinically suspect cases identified in patients, healthcare workers, volunteers and/or visitors during a two week period of time. The Management of Scabies Outbreaks in California Health Care Facilities indicated ?All outbreaks should be reported immediately to both the local (county) health officer) and to the Licensing and Certification District Office that serves the county where the facility is located.? The Licensing and Certification is the ?the Department.? Reporting provides the opportunity for consultation with staff experienced in the control of scabies. b. During an observation with LVN 1, on 8/21/15 at 4:35 p.m., Resident 3 had notable rashes throughout the body. A review of Resident 3's admission face sheet, indicated the resident was admitted on 3/14/15, with diagnoses that included sepsis (a potentially life-threatening complication of an infection) and muscle weakness. A review of Resident 3's MDS, dated 6/19/15, indicated the resident was unable to make her needs known and was rarely able to understand others, had severe impairment in cognitive skills, and required total dependence (full staff performance every time) from staff in ADLs. A review of Resident 3's Treatment Record for August 2015 indicated the resident had an order for Elimite cream on 8/12/15 and the Elimite cream was given on the same day during the 3-11 p.m. (evening) shift. A review of Resident 4's admission face sheet indicated the resident was admitted on 2/26/15, with diagnoses that included UTI and dysphagia (difficulty swallowing and/or eating). A review of Resident 4's MDS, dated 6/19/15, indicated the resident was able to make her needs known and was able to understand others, had minimal impairment in cognitive skills, and required total dependence (full staff performance every time) from staff in ADLs. A review Resident 4's Treatment Record for August 2015 indicated the resident had an order for Elimite cream on 8/20/15 and the Elimite cream was given on the same day during the 3-11 p.m. shift. On 8/24/15 at 2:50 p.m., during an interview, the DON and the administrator stated Resident 1 had returned from the hospital, on 8/22/15, and was confirmed with a diagnosis of scabies, which led the facility to conduct a skin sweep (or assess) other residents for possible exposure to scabies. The DON stated that because within a two week period, Resident 1 had a confirmed diagnosis of scabies, and Resident 3 and 4 were clinically suspected cases of scabies, the facility now had an outbreak. During the interview, the DON stated she did not know that it was considered an outbreak when there were only two clinically suspected cases of scabies. On 8/24/15 at 4:10 p.m., the facility staffs were observed placing contact isolation carts and signs outside residents' rooms. The facility failed to report an outbreak of scabies to the Department (the Licensing and Certification District Office) within 24 hours. The above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 940000095 |
RIVIERA HEALTHCARE CENTER |
940012637 |
A |
12-Oct-16 |
ZJTD11 |
29375 |
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. F157 CFR ? 483.10 (b) (11) Notification of Changes (i) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is 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). (ii) The facility must also promptly notify the resident and, if known, the resident's 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. (iii) The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member. The facility failed to provide necessary care and services to Residents 4, 17, and 28 to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. The failures include but are not limited to: 1. For Resident 4: (a) Accurately assess, develop a care plan, and notify the physician in a timely manner of Resident 4's left jaw/tooth pain that started on 12/10/14. The resident was evaluated by the dentist on 12/15/14, which was five days after the onset of the left jaw/tooth pain. (b) Accurately assess, develop a care plan and notify the physician timely on 12/11/14, when Resident 4 experienced severe left knee pain. The surveyor intervened on 12/12/14 and the physician was notified on 12/12/14, which was more than 24 hours after the onset of the pain, and gave orders for diagnostic tests. This deficient practice resulted in Resident 4 suffering severe pain from 12/10/14 to 12/17/14, a total of seven days. Resident 4 was given Lovenox (medication used to prevent blood clot) 40 mg (milligrams) per injection and Clindamycin (medication used to treat infection) 300 milligrams (an antibiotic) every six hours for two weeks for osteomyelitis (bone infection). Resident 4 continued to complain of severe (pain scale 8/10) left knee pain and subsequently transferred to the acute hospital on 12/16/14. (c) Notify the physician of Resident 4's elevated blood sugar of more than 400 mg/dl (milligrams/deciliter) for a total of five times as indicated in the resident's record from 11/2/14 to 12/9/14. (d) Recheck Resident 4's blood sugar of more than 300 mg/dl, 30 minutes after the initial reading, for a total of 16 times as stipulated in the facility's policy and procedure from 11/2/14 to 12/8/14. (e) Monitor Resident 4's 6:30 a.m. blood sugar level for four days on 12/4/14, 12/7/14, 12/8/14 and 12/9/14. These deficient practices resulted in Resident 4 having hyperglycemic (uncontrolled high blood sugar level) episodes that included nervousness, anxiety, and increased thirst placing the resident at risk for coma or death. 2. The facility failed to ensure that blood sugar (BS) levels were consistently monitored for two of four residents (Resident 17 and 28) with diabetes and who were on hemodialysis treatment (a medical procedure to remove waste and fluid from the blood): (a) Resident 17's 6:30 a.m. blood sugar (BS) levels were not taken for a total of 13 times from 11/8/14 to 12/11/14. (b) Resident 28, whose usual BS levels ranged from 150-461 at 11:30 am, did not have the BS levels taken at 11:30 a.m. for a total of eight (8) times from 11/3/14 to 12/15/14. 3. The facility failed to inform the physicians of the discrepancy on the blood sugar monitoring schedule; failed to communicate with the Dialysis Center of the need to monitor Resident 17 and 28's blood sugar levels by finger-stick while the residents were in the Dialysis Center. This deficient practice placed Residents 17 and 28 at risk for hypoglycemic (abnormally low BS level) or hyperglycemia (abnormally high BS level) episodes that could result to coma or death. 1. a. A review of the admission Face Sheet indicated Resident 4 was originally admitted to the facility on 9/28/13 and readmitted on 12/8/13, with diagnoses that included diabetes mellitus (a metabolism disorder that affects the body's ability to use blood sugar resulting in high levels of sugar in the blood). A review of the Minimum Data Set (MDS), a resident assessment and care planning tool, dated 8/25/14, indicated that Resident 4 was able to make self-understood and understand others and required extensive assistance (weight bearing support) with two person physical assist in bed mobility, locomotion on the unit, dressing, toilet use and personal hygiene. On 12/10/14 at 8:05 a.m., Resident 4 was observed sitting in bed with her food tray in front of her. Resident 4 was grimacing and was holding her left cheek and complained of difficulty chewing due to left jaw and tooth pain, which she described as severe, 10/10 pain rating scale (0=no pain-10=severe pain). On 12/11/14 at 1:30 p.m., Resident 4 was observed sitting in her wheelchair inside her bedroom watching television (TV). During an interview, Resident 4 stated that her left knee had been painful. She stated that she had been given pain medication but it was not working. Resident 4 tried to lift her left leg and grimaced and stated, "I can't even lift my leg, it hurts." Resident 4 stated she had to hold her urine and delay toileting because of the left knee pain when she stands. During an interview on 12/11/14 at 1:35 p.m., LVN 6 stated that he was not aware of Resident 4's complaint of left knee pain, but stated he would give her pain medication. The review of Resident 4's clinical record on 12/11/14 indicated that there was no written plan of care for the management of the resident's jaw/tooth ache and left knee pain. A review of Resident 4's physician's order, dated 7/8/14, indicated to administer Norco (a narcotic pain reliever) 5/325 milligrams (mg) orally every 6 hours for severe pain. The Pain Assessment Flow-sheet indicated that on 12/11/14, Resident 4 received Norco 5/325 mg for three doses; on 12/12/14, four doses; on 12/13/14, three doses; on 12/14/14, four doses; and on 12/16/14, four doses. The Nursing Note, dated 12/10/14, during the 7 a.m. to 3 p.m. shift, indicated Resident 4 complained of left side facial pain (tooth pain, a 10/10 pain rating) and the physician was notified. There was no documentation of the physician's response. During the 3 p.m. to 11 p.m. shift, Resident 4 continued to complain of pain to the left side of the face (tooth pain, an 8/10 pain rating). The Nursing Note, dated 12/11/14, during the 7 a.m. to 3 p.m. shift, indicated that Resident 4 complained of left knee pain on a pain scale of 8/10 with left foot 3+ edema (swelling). There was no documented evidence that the physician was notified of the new onset of severe left knee pain. During the 3 p.m. to 11 p.m. shift, Resident 4 complained of left knee pain on a pain scale of 8/10 and the physician was called but could not be reached. During the 11 p.m. to 7 a.m. shift, Resident 4 complained of left facial pain on a pain scale of 8/10. On 12/12/14, during the 7 a.m. to 3 p.m. shift, Resident 4 complained of left knee pain on a pain scale of 8/10 and was unable to lift left leg. There was no documented evidence the physician was informed of Resident 4's continued complaint of left facial pain and left knee pain. On 12/10/14 at 9 a.m., during an interview, LVN 6 stated that he notified the physician the morning of 12/10/14 about Resident 4's left side facial pain (tooth pain) 10/10 pain rating and was told to continue to give Norco, a narcotic pain medication. On 12/11/14 at 8:05 a.m., during an interview, LVN 6 stated he did not follow up with the physician. LVN 6 stated he did not inform the social worker or the dentist regarding Resident 4's continued complaint of dental pain. On 12/12/14 at 9 a.m., during an interview, Resident 4 stated she continued to have left tooth pain on a pain scale of 8/10 and left knee pain on a pain scale of 8/10. Resident 4 stated, "They are giving me pain medication, it helps but it's painful again. It's difficult to chew. I was forced to swallow my food." On 12/12/14 at 9:10 a.m., LVN 6 was interviewed if the physician was notified of Resident 4's complaint of left knee pain and swelling to the left foot, LVN 6 stated, "Oh, I haven't called the doctor." LVN 6 went to the phone and called the physician. The Daily Licensed Nurses Notes, dated 12/12/14, during the 3 p.m. to 11 p.m. shift, indicated that LVN 6 notified the physician of Resident 4's change of condition and an X-ray of the left knee was ordered. On 12/12/14 at 10:05 a.m., the assistant director of nursing (ADON) stated, "The dentist will be informed about Resident 4's complaint as soon as possible." On 12/15/14, five days after onset of left teeth pain, Resident 4 was seen by the dentist with the following documentation by the dentist, "Resident complained of pain from dentures, not teeth. Lower partial was adjusted due to sore spot. Recommended tooth extraction and consented for full lower denture." On 12/16/14 at 4 p.m., when asked about Resident 4's severe left knee pain on 12/11/14 on the 3 p.m. to 11 p.m. shift and the physician could not be reached, LVN 4 stated he did not report to the nursing supervisor but endorsed to the night shift to follow up with the physician. LVN 4 stated the night shift did not follow up with the physician. On 12/17/14 at 12:20 p.m., during an interview, Resident 4 stated, "The tooth ache has improved, I can eat better now. They adjusted my dentures." A review of Resident 4?s x-ray result done on 12/12/14 at 6:49 p.m. indicated "Suspicious for infection/osteomyelitis (bone infection)." A review of the physician's order, dated 12/12/14 at 10:45 p.m., indicated to do CT scan (computed tomography scan is an imaging method that uses x-rays to create pictures of the body) to Resident 4?s left knee and to place a bandage on the left knee. Lovenox (medication use to prevent blood clot) 40 mg (milligrams) per injection was ordered. On 12/13/14, there was a physician's order for Clindamycin 300 milligrams (an antibiotic) every six hours for two weeks for osteomyelitis. On 12/12/14 at 12 pm, during an interview and record review with the director of nursing and the registered nurse supervisor (RN 1) regarding lack of care plan for pain management for Resident 4's left knee pain and left tooth pain, they stated they should have accurately assessed and developed care plans for Resident 4's pain. A review of the facility's policy and procedure titled, "Pain", dated 2/14/11, indicated that the facility was to assess resident's pain and to provide pain management as indicated in the physician's order. The attending physician shall be notified if a resident's pain management regimen was ineffective; the nurse shall document in the licensed nurse notes, update the pain assessment and revise the plan of care. A review of the Nursing Note, dated 12/16/14, indicated that Resident 4 continued to complain of severe (pain scale 8/10) left knee pain. Resident 4 was transferred to the hospital on 12/16/14. 1b. On 12/9/14 at 11:50 a.m., during an interview, Resident 4 stated, "I was told by my nurse that my blood sugar had been high, almost 500. On Saturday (12/7/14), I told them (the nurses) to call my doctor, so he can give me more medication (insulin, a medication used to control high blood sugar levels). The nurse tried to call my doctor, but she could not get hold of him. She told me maybe because it was a weekend." Resident 4 stated, "They (the staff) did not check my (blood) sugar today (12/9/14 at 6:30 a.m.). I don't think they checked it yesterday (12/8/14 at 6:30 a.m.). I did not get any (insulin) injection today (12/9/14 at 6:30 a.m.). Sometimes they check my blood sugar, sometimes not." Resident 4 stated, "When my blood sugar is high, I feel nervous, like anxious and shaky. I asked them to give me anxiety pills, but they don't give it to me." A review of the physician's order for Resident 4, dated 11/28/14, indicated to check finger stick (FS) blood sugar (BS) before breakfast and dinner and to give regular (fast acting) insulin (medication used to control high blood sugar) sliding scale (a predetermined amount of insulin to be given based on blood sugar test result) as follows: BS 150-199=1 units (u) subcutaneous (SQ) injection (a shot that is given into the layer of fat between the skin and the muscle), 200-249= 3 u SQ, 250-299=5 u SQ, 300-349=7 u SQ, 350-399=8 u SQ, > (more than) 400 =10 u and call physician, or for BS < (less than) 60, call physician and do hyperglycemia /hypoglycemia protocol (a set of procedures to follow). A review of Resident 4's plan of care titled, "Risk for hypoglycemia and hyperglycemia related to diabetes", dated 12/9/14, indicated to monitor Resident 4 for hypoglycemia and hyperglycemia; check finger-stick blood sugar as ordered; and to initiate nursing measures for hypoglycemia/hyperglycemia immediately and to notify the physician promptly. During an interview and review of Resident 4's Medication Administration Record (MAR) on 12/9/14 at 12 p.m., the licensed vocational nurse (LVN 3) stated if the blood sugar was not documented in the MAR, the physician was not notified. On 12/9/14 at 12:20 p.m., Resident 4's medical records were reviewed with RN 1. The FS blood sugar record indicated Resident 4's blood sugar levels at 4:30 p.m. were as follows: 11/2/14=331 mg/d (milligram/deciliter), 11/4/14=429mg/dl, 11/7/14=373mg/dl, 11/10/14=327mg/dl, 11/12/14=368 mg/dl, 11/13=357mg/dl, 11/16/14=450mg/dl, 11/17/14=497mg/dl,11/20/14=390mg/dl, 11/30=358mg/dl 12/1/14=366mg/dl,12/2/14=380mg/dl, 12/3/14=390mg/dl, 12/4/14=431mg/dl, 12/7/14=418 mg/dl and 12/8/14=384 mg/dl (normal blood sugar reference range 70-130). On 12/4/14, 12/7/14, 12/8/14 and 12/9/14 at 6:30 a.m., Resident 4's blood sugar results were not documented. A review of Resident 4's Nursing Notes and Physician Progress Notes had no documented evidence that the physician had been informed of blood sugar levels > 400 mg/dl according to the physician's order on 11/4/14, 11/16/14, 11/17/14, 12/4/14, and 12/7/14. There were no documented evidence that the blood sugar levels were rechecked 30 minutes after when the blood sugar was >300mg/dl, except on 12/7/14, 16 times from 11/2/14 to 12/8/14. On 12/9/14 at 12:30 p.m., in an interview, RN 1 stated she was not aware that Resident 4's blood sugars were not being documented and the physician was not being notified. RN 1 stated if there was a significant change in the resident's condition, it should be reported to the charge nurse or to the nursing supervisor, who reports the change of condition to the physician. On 12/10/14 at 6 a.m., LVN 5 stated he checked the blood sugar but did not document the result in the FS blood sugar record and medication reconciliation sheet because, "It was an oversight on my part." LVN 5 stated he did not document the result because of "Mental lapse. I'm not sure." He stated he was aware Resident 4's blood sugar had been high which may be due to dietary effect because Resident 4 tends to have a lot of outside food brought by family. On 12/16/14 at 7:15 a.m., during an interview with RN 2 regarding the facility's procedure on rechecking high blood sugar level, she stated the blood sugar was to be rechecked after one hour or so or depending on the physician's order. RN 2 admitted she had not reviewed the facility's policy and procedure on Hypoglycemia/Hyperglycemia. On 12/16/14 at 4:30 p.m., during an interview, LVN 4 stated he checked the blood sugar of Resident 4 on 12/4/14 at 4:30 p.m. and documented the result as 431 mg/dl. LVN 4 stated he forgot to inform the physician and did not document the result of the blood sugar after it was rechecked. LVN 4 stated he had not read or reviewed the facility's policy and procedures on Change of Condition, Physician Contact and Hypoglycemia/Hyperglycemia. The review of Resident 4's Nursing Progress Note, dated 12/7/14 (Sunday), at 4 p.m., indicated, "The resident was asking if her insulin can be adjusted. The nurse explained to the resident, it is Sunday evening and the doctor is probably on two days off, and the issue will be followed up in the morning." There was no documentation that a physician was informed on 12/8/14, on a Monday. On 12/16/14 at 12:20 p.m., during an interview, Resident 4's primary physician stated he could not remember if he was informed about Resident 4's high blood sugar level results but he ordered insulin sliding scale for high blood sugar levels and the expectation was for the blood sugar to be rechecked after 30 minutes. If the blood sugar continues to be high, the physician should be informed. According to the facility's policy and procedure titled, "Hypoglycemia/Hyperglycemia", dated 3/31/06 indicated if increased thirst and dry mouth, complaints of aches and breathing and increased perspiration exist, a finger stick will be done by the licensed nurse to determine blood sugar level. If blood sugar level is high above 300, the following must be done; 1. Check Physician's order for sliding scale coverage and administer additional insulin according to physician's orders, 2. Constantly monitor the patients for any changes, 3. Recheck blood sugar by finger stick every 30 minutes, 4. Notify family/responsible party of change in condition and update plan of care. According to the facility's policy and procedure titled, "Change of Condition, Physician Contact," dated 3/31/06, indicated to notify the attending physician of any significant change in resident's condition or to report an incident. On 12/16/14 at 5 p.m., during an interview, Resident 4 stated, "When my (blood) sugar is high I feel very thirsty, I asked my daughter for soda. I just wanted to eat, food or cookies." According to , (1/22/15) Diabetes is a chronic condition that causes hyperglycemia (high blood sugar). The common signs of diabetes includes: being thirsty, frequent urination, feeling hungry or tired and sores that heal slowly. According to , (1/22/15) Patients with poorly controlled diabetes may be subject to acute complications of diabetes, including dehydration, poor wound healing, and coma. "Older Adults" Diabetes Care 2015; 38(suppl.1):567-569/DOI:10.2337/dc15-SO13. 2. a. On 12/11/14 at 12:40 p.m., Resident 17 was observed sitting at bedside getting ready for lunch. During an interview at the time, Resident 17 stated he just returned from the dialysis center. Resident 17 reported feeling hungry because he usually leaves the facility at around 4 a.m. and would not return until around 11 a.m. A review of the admission Face Sheet indicated that Resident 17 was admitted to the facility on 9/4/13 with diagnoses that included diabetes mellitus, end stage renal disease (kidney failed to remove excess toxins, fluid and minerals in the blood), and hemodialysis status. A review of the MDS, dated 9/10/14, indicated Resident 17 was mentally intact, able to make self-understood and understand others, required extensive assistance with bed mobility, locomotion on and off unit, dressing, and personal hygiene. A review of Resident 17' Physician Order, dated 9/4/13, indicated dialysis three times a week every Tuesday, Thursday and Saturday at 5 a.m. The Physician's Order, dated 10/31/14, indicated to check blood sugar (BS) level before breakfast and dinner and to administer regular insulin according to the sliding scale as follows: BS 150-200=2 units (u) subcutaneous (SQ), 201-250= 4 u SQ, 251-300=6 u SQ, 301-350=8 u SQ, 351-400=10 u SQ, call physician for BS<60 or > 400. Administer Novolog 70/30, 5 units SQ (combination of slow and fast acting medication to lower blood sugar) two times a day, hold if meals will be skipped. A review of Resident 17?s Fingerstick record for 11/2014 and 12/2014 indicated the resident?s blood sugar levels ranged from 81 - 215. A review of the plan of care titled, "Hemodialysis", dated 9/4/13, and another plan of care titled, "Risk for hypoglycemia and hyperglycemia related to diabetes mellitus" did not address Resident 17's need for blood sugar level monitoring at 6:30 a.m. while Resident 17 was in the dialysis center. A review of the "Nurses Dialysis Communication Record," (a record utilized by the facility and the dialysis center to communicate the residents' care needs), dated 12/2, 12/6, 12/9, 12/14, 12/13 and 12/14/14, did not indicate Resident 17's blood sugar level at 6:30 a.m. while in the dialysis center. There was no documented evidence in the Nurses Dialysis Communication Record that the facility communicated the need to have Resident 17's blood sugar level monitored at 6:30 a.m. On 12/10/14 at 11:20 a.m., the Fingerstick record for the months of 11/2014 and 12/2014 for Resident 17 were reviewed with RN 1. There were no blood sugar level results at 6:30 a.m. on the following dates: 11/8/14, 11/13/14, 11/15/14, 11/18/14, 11/20/14, 11/22/14, 11/25/14, 11/27/14, 11/29/14, 12/2/14, 12/6/14, 12/9/14 and 12/11/14, a total of 13 times. On 12/10/14 at 07:20 a.m., during an interview, RN 1 stated Resident 17's blood sugar levels were not taken at 6:30 a.m. because the resident was in the dialysis center. RN 1stated that Resident 17 usually leaves the facility around 4 a.m. and returns at around 11 a.m. RN 1 stated the care plan should address Resident 17's need to have the blood sugar level checked at 6:30 a.m. on the days he goes to hemodialysis. b. According to the admission Face Sheet, Resident 28 was admitted to the facility on 9/15/14, with diagnoses that included diabetes, end stage renal disease and hemodialysis status. A review of the MDS, dated 9/22/14, indicated Resident 28 was cognitively (mentally) intact, able to make self-understood and understand others, required extensive assistance with one person physical assist with bed mobility, dressing, personal hygiene and limited assistance with eating. According to Resident 28's physician's order, dated 11/14/14, indicated to check finger-stick (FS) blood sugar before meals and at bedtime and cover with Novolog insulin sliding scale as follows: BS 151-200=2 units (u) subcutaneous (SQ), 201-250= 4 u SQ, 251-300=6 u SQ, 301-350=8 u SQ, 351-400=10u SQ, >401=12 u SQ and call physician for BS<70 or > 401. Administer Novolog mix 70/30, 33 units every day before breakfast and Novolog mix 70/30, 19 units every day at 5 p.m. before dinner. Another physician's order, dated 10/23/14, indicated dialysis three times a week every Monday, Wednesday and Friday at 12:30 p.m., pick up time was 11:30 a.m. A review of Resident 28?s Fingerstick record for 11/2014 and 12/2014 indicated the resident?s blood sugar levels ranged from 150- 461. A review of Resident 28's plans of care titled, "Risk for hypoglycemia and hyperglycemia related to diabetes mellitus", dated 10/23/14, and "Hemodialysis", dated 10/23/14, did not address the need for blood sugar monitoring when Resident 28 leaves the facility to go to the Dialysis Center for hemodialysis treatment at 11:30 a.m. A review of Resident 28's "Nurses Dialysis Communication Record," dated 12/3, 12/5, 12/8, 12/10, 12/12 and 12/15/14, did not indicate Resident 28's blood sugar levels at 11:30 a.m. nor the 11:30 a.m. blood sugar level monitoring ordered by the physician was communicated to the dialysis center via Nurses Dialysis Communication Record. On 12/16/14 at 7:50 a.m., Resident 28's Fingerstick records for the months of 11/2014 and 12/2014 were reviewed with RN 1 that indicated there were no blood sugar level results at 11:30 a.m. on the following dates: 11/3/14, 11/7/14, 11/14/14, 11/17/14, 11/21/14, 12/14/14, 12/8/14, 12/15/14, for a total of 8 times. On 12/16/14 at 7:50 a.m., during an interview, RN 1 stated Resident 28's blood sugar was not monitored because he leaves for dialysis at 11 a.m. The blood sugar was scheduled to be checked at 11:30 am. On 12/16/14 at 10:10 a.m., during an interview, the director of staff development (DSD) stated she had called the dialysis center and was informed by the staff that blood sugar monitoring by FS was not performed at the dialysis center. The DSD stated the Dialysis Communication Record that the facility used to communicate with the dialysis center did not have a place to put the latest blood sugar of the resident. On 12/16/14 at 10:55 a.m., during an interview, the assistant director of nursing (ADON) stated, "The communication record to the dialysis center does not have a space for blood sugar check or any medication given to resident prior to leaving the facility and the staff does not always call the dialysis center for patient report." https://labtestsonline.org/understanding/analytes/glucose/tab/test Therefore, facility failed to provide necessary care and services to Residents 4, 17, and 28 to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. The failures include but are not limited to: 1. For Resident 4: (a) Accurately assess, develop a care plan, and notify the physician in a timely manner of Resident 4's left jaw/tooth pain that started on 12/10/14. The resident was evaluated by the dentist on 12/15/15, which was five days after the onset of the left jaw/tooth pain. (b) Accurately assess, develop a care plan and notify the physician timely on 12/11/14, when Resident 4 experienced severe left knee pain. The surveyor intervened on 12/12/14 and the physician was notified on 12/12/14, which was more than 24 hours after the onset of the pain, and gave orders for diagnostic tests. This deficient practice resulted in Resident 4 suffering severe pain from 12/10/14 to 12/17/14, a total of seven days. Resident 4 was given Lovenox (medication used to prevent blood clot) 40 mg (milligrams) per injection and Clindamycin (medication used to treat infection) 300 milligrams (an antibiotic) every six hours for two weeks for osteomyelitis (bone infection). Resident 4 continued to complain of severe (pain scale 8/10) left knee pain and subsequently transferred to the acute hospital on 12/16/14. (c) Notify the physician of Resident 4's elevated blood sugar of more than 400 mg/dl (milligrams/deciliter) for a total of five times as indicated in the resident's record from 11/2/14 to 12/9/14. (d) Recheck Resident 4's blood sugar of more than 300 mg/dl, 30 minutes after the initial reading, for a total of 16 times as stipulated in the facility's policy and procedure from 11/2/14 to 12/8/14. (e) Monitor Resident 4's 6:30 a.m. blood sugar level for four days on 12/4/14, 12/7/14, 12/8/14 and 12/9/14. These deficient practices resulted in Resident 4 having hyperglycemic (uncontrolled high blood sugar level) episodes that included nervousness, anxiety, and increased thirst placing the resident at risk for coma or death. 2. The facility failed to ensure that blood sugar (BS) levels were consistently monitored for two of four residents (Resident 17 and 28) with diabetes and who were on hemodialysis treatment (a medical procedure to remove waste and fluid from the blood): (a) Resident 17's 6:30 a.m. blood sugar (BS) levels were not taken for a total of 13 times from 11/8/14 to 12/11/14. (b) Resident 28, whose usual BS levels ranged from 250-460, did not have the BS levels taken at 11:30 a.m. for a total of eight (8) times from 11/3/14 to 12/15/14. 3. The facility failed to inform the physicians of the discrepancy on the blood sugar monitoring schedule; failed to communicate with the Dialysis Center of the need to monitor Resident 17 and 28's blood sugar levels by finger-stick while the residents were in the Dialysis Center. This deficient practice placed Residents 17 and 28 at risk for hypoglycemic or hyperglycemia episodes that could result to coma or death. The above violations either jointly, separately, or in combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result to the residents. |
| 940000076 |
ROYAL OAKS CARE CENTER |
940012733 |
B |
8-Nov-16 |
IKW511 |
6596 |
?483.25(e)(2) A resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. On September 14, 2016, at 8 a.m., an unannounced visit was made to the facility to conduct an annual recertification survey. Based on observation, interview, and record review, the facility staff failed to assess Resident 7's joint mobility accurately, monitor resident response to treatment exercises and report to the rehabilitation department for reassessment and further intervention. This resulted in delayed identification of contractures (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching; this can lead to permanent disability) to resident's left shoulder, left middle/ring/pinky (small) fingers, and left ankle. On September 15, 2016, at 4 p.m., Resident 7 was observed in bed, lying on his right side. The resident was alert, oriented and verbally responsive. He stated he had weakness on his left side of the body, and received exercises from the RNA. On September 20, 2016, at 3:35 p.m., Resident 7 was observed in the room, he stated his left arms and leg needed help to move, and he was unable to open his left fingers fully. He stated he needed a ball to keep his left fingers open, and occasionally when he opened his left fingers, he experienced pain that radiated to his left upper arm. According to the Admission Record, Resident 7 was admitted to the facility on August 2014, with diagnoses that included flaccid (lacking force) hemiplegia affecting the non-dominant side, diabetes mellitus (abnormally high blood sugar levels), and unspecified injury to the sacral spinal cord. The Minimum Data Set (MDS, (MDS, a standardized assessment and care screening tool), dated April 22, 2016, and June 19, 2016, indicated Resident 7's cognitive skills for daily decision-making were intact. The MDS indicated the resident required limited assistance from the staff with bed mobility, dressing, and extensive assistance with transfer, hygiene, and bathing. The MDS indicated the resident had no functional limitation in range of motion and received restorative nursing program five (5) days a week. A Joint Mobility Assessment dated July 19, 2016 documented by the PT (physical therapist) indicated Resident 7 had no joint mobility limitations. A review of Resident 7's physician's orders dated August 14, 2014 indicated the following: 1. RNA to perform AAROM (active assistive range of motion) exercises to resident's left upper extremity daily five times a week. 2. RNA to perform AROM (active range of motion) exercises on the right upper extremity as tolerated daily five times a week. A physician's order dated August 28, 2014 indicated the following: 1. RNA to perform ambulation using the parallel bars every day as tolerated five times a week. 2. RNA to perform sit to stand exercises, using the parallel bars as tolerated every day five times a week. A review of Resident 7's care plan dated August 15, 2014, for AROM/AAROM exercises secondary to spinal cord injury and left sided hemiparesis indicated the resident was on the RNA program. The approach plan included for the RNA to perform the exercises, monitor for pain and discomfort, medicate for pain as needed, monitor for tolerance of the exercises and notify the physician if unable to tolerate, and the rehabilitation department to assess at all times for possible decline. Another care plan with the same date indicated the resident was on RNA program for ambulation exercises secondary to left side hemiparesis and spinal cord injury. The approach plan included for the RNA to ambulate as tolerated daily five times a week, and the rehabilitation department to assess for possible decline at all times. A review of Resident 7's Nursing Weekly Summaries from August 3, 2016, August 10, 2016, August 17, 2016, August 24, 2016, one undated entry, September 7, 2016, and September 14, 2016, indicated the resident had no contractures or joint mobility limitations, and on the RNA program five times a week. A review of Resident 7's RNA Treatment Sheet, from August 1, 2016, through September 20, 2016, indicated the resident received the range of motion exercises as ordered by the physician. There was no documentation that the resident had problem opening his left hand fingers. On September 22, 2016, at 10 am, the PT came to assess Resident 7's joint mobility status. The PT indicated in his report that the resident had moderate joint mobility limitations on the left shoulder, left middle/ring/pinky fingers, and left ankle. The PT recommended a left hand splint to prevent any further decline in the ROM. During an interview on September 22, 2016, at 10:20 a.m., PT stated he had not received report of any changes in the resident's joint mobility status from the nursing staff. A review of the facility's undated General Restorative and Supportive Nursing Care policy and procedures indicated the following: - Each resident will be provided with an individualized restorative and supportive plan of care to allow the resident the highest degree of independence possible within their physical and mental capabilities; - Provide early detection and intervention when independence declines in order to prevent complications and maintain the resident at their highest level of functioning. - Provide range of motion to maintain joint mobility, prevent contractures or prevent further deterioration and complications of limited ROM. According to the facility's undated policy and procedures for Joint Mobility Assessment indicated, that all residents will be assessed for joint mobility limitations upon admission. The facility staff failed to assess Resident 7's joint mobility accurately, monitor resident response to treatment exercises and report to the rehabilitation department for reassessment and further intervention. This resulted in delayed identification of contractures to resident's left shoulder, left middle/ring/pinky fingers, and left ankle. The above violation had a direct or immediate relationship to the health, safety, and/or security of Resident 7. |
| 940000076 |
ROYAL OAKS CARE CENTER |
940012734 |
B |
8-Nov-16 |
IKW511 |
7273 |
?483.25(e)(2) A resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. On September 14, 2016, at 8 a.m., an unannounced visit was made to the facility to conduct an annual recertification survey. Based on observation, interview, and record review, the facility staff failed to assess Resident 9's joint mobility accurately, monitor resident response to treatment exercises and provide range of motion exercises as ordered by the physician. This resulted in unidentified development of contracture (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching; this can lead to permanent disability) to resident's right wrist, right hand fingers, right knee and right toes. On September 14, 2016, at 3:10 p.m., during the initial tour of the facility accompanied by licensed vocational nurse 3 (LVN 3), Resident 9 was observed in bed. The resident was alert, verbally responsive, and was observed with contractures on the right wrist and fingers. LVN 3 stated the resident was on the RNA (restorative nursing assistant, a nursing aid specifically trained by the therapist to help residents maintain (range of motion/ambulation) any progress the resident made during therapy treatments, enabling them to function at a high capacity) program. According to the Admission Record, Resident 9 was admitted to the facility on March 6, 2015, with diagnoses that included cerebrovascular disease (CVA, stroke) with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body). The Minimum Data Set (MDS, a standardized assessment and care screening tool), dated March 17, 2016, and June 13, 2016, indicated Resident 9's cognitive skills for daily decision-making were moderately impaired. The resident required limited assistance from the staff with bed mobility, dressing, and extensive assistance with transfer, personal hygiene, and bathing. The MDS indicated the resident had no functional limitation in range of motion and was on the restorative nursing program five days a week. A review of Resident 9's care plan dated September 23, 2015, indicated the resident was on the RNA program for passive range of motion (PROM, performed by the RNA) exercises due to CVA with right hemiplegia. The approach plan indicated the following: - RNA was to provide PROM exercises to the right upper and lower extremities five (5) times a week as tolerated. - Observe the resident for pain and discomfort, and notify the physician immediately. - Medicate the resident for pain as needed - Observe the resident for PROM exercises tolerance and notify the physician if not able to tolerate the exercises. A review of September 2016, Resident 9's summary physician's orders indicated an order dated March 11, 2016, for the RNA to perform PROM on resident's right lower extremities/right upper extremities as tolerated every day; five times a week. A Joint Mobility Assessment dated June 13, 2016 documented by the PT (physical therapist) indicated Resident 9 had no joint mobility limitations. A review of the Nursing Weekly Summary dated July 3, 2016, July 16, 2016, July 17, 2016, July 24, 2016, July 31, 2016, August 7, 2016, August 14, 2016, August 21, 2016, and September 4, 2016 indicated Resident 9 was on the RNA program for ROM, and indicated that the resident had no contractures. A review of Resident 9's RNA Treatment Record, dated August 1, 2016, through September 18, 2016, indicated the PROM exercises were provided and the resident tolerated the exercises. There was no documentation that the resident had developed contractures on the right wrist, right hand fingers, and right knee. During an interview on September 19, 2016, at 11:40 a.m., Resident 9 stated he had a stroke. The resident stated he could not remember when his right wrist and fingers started getting stiff and contracted. On September 19, 2016, at 12:05 p.m., during range of motion exercises observation, RNA 1 did not provide ROM exercises on Resident 9's contracted right wrist, right hand fingers and right toes. During an interview on September 19, 2016, at 12:15 p.m., RNA 1 was informed that ROM exercises on Resident 9's right wrist, right hand fingers, and right foot toes were not observed. RNA 1 stated sometimes there is an order not to exercise the resident's fingers. However, there was no documented physician order not to provide ROM exercise to resident's fingers. RNA 1 offered no further explanation why the exercises were not provided to the right wrist, right hand fingers, and right toes as ordered. During an interview on September 19, 2016, at 3 p.m., the assistant director of nursing (ADON) stated she was unable to find documentation about the Resident 9's contracted right wrist and right hand fingers. ADON stated she will make an appointment for PT to come and assess the resident's joint mobility status. On September 20, 2016, at 11:30 a.m., the PT came to assess Resident 9's joint mobility status. The PT notes indicated that the resident had moderate joint mobility limitations on the right upper extremity and left lower extremity. The PT notes indicated a recommendation for splint application to the right hand. During an interview on September 20, 2016, at 1:55 p.m., RNA 1 stated she was not sure when the resident's right hand contractures developed. During an interview on September 22, 2016, at 10:20 am, PT stated there was a problem about the joint mobility assessment form currently being used by the facility. There was no accurate description of Resident 9's right wrist extension contracture and the right knee extension contracture. He also stated he could not say when those contractures started, because these were not reported to him by the nursing staff. A review of the facility's undated General Restorative and Supportive Nursing Care policy and procedures indicated the following: - Each resident will be provided with an individualized restorative and supportive plan of care to allow the resident the highest degree of independence possible within their physical and mental capabilities; - Provide early detection and intervention when independence declines in order to prevent complications and maintain the resident at their highest level of functioning. - Provide range of motion to maintain joint mobility, prevent contractures or prevent further deterioration and complications of limited ROM. According to the facility's undated policy and procedures for Joint Mobility Assessment indicated, that all residents will be assessed for joint mobility limitations upon admission. The above violation had a direct or immediate relationship to the health, safety, and/or security of Resident 9. |
| 940000076 |
ROYAL OAKS CARE CENTER |
940012738 |
B |
8-Nov-16 |
IKW511 |
5574 |
?483.25(e)(2) A resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. On September 14, 2016, at 8 a.m., an unannounced visit was made to the facility to conduct an annual recertification survey. Based on observation, interview, and record review, the facility staff failed to assess Resident 10's joint mobility status upon admission as indicated in the facility's policy and procedures. This resulted in resident not receiving necessary exercises to prevent development of contractures (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching; this can lead to permanent disability) to resident's right shoulder, bilateral ankles, and moderate joint mobility limitation on bilateral hip and knees. On September 15, 2016, at 11:20 a.m., during the treatment observation, Resident 10 was in bed. The resident was alert and rarely responded to verbal inquiry. Resident 10's legs remained flexed during the whole treatment. On September 16, 2016, at 1:00 p.m., the resident's family member visited and encouraged the resident to extend both knees/legs, but the resident did not move. The resident's family member asked the resident why he did not want to extend the knees/legs, and the resident stated it was painful. According to the Admission Record, Resident 10 was admitted to the facility on July 13, 2016, with diagnoses that included muscle wasting and atrophy (decrease in size of a body), adult failure to thrive, diabetes mellitus (abnormally elevated blood sugar levels), and dementia (a progressive deterioration of physical and mental function). The Minimum Data Set (MDS, a standardized assessment and care screening tool), dated July 25, 2016, indicated Resident 10's cognitive skills for daily decision making were severely impaired. The resident required supervision with eating, extensive assistance from the staff with bed mobility, locomotion in the room, dressing, and was totally dependent for transfer, locomotion off the unit, toilet use, personal hygiene, and bathing. The MDS indicated the resident had no functional limitation in range of motion. A review of Resident 10's recapped physician's orders for September 2016, indicated there was no specific order to maintain the joint mobility status of the resident. A review of Resident 10's care plan dated July 25, 2016 for self-care deficit related to the multiple diagnoses. The approach plans indicated that the rehabilitation department evaluate and assess the resident for treatment as indicated, and notify the physician for any changes. A review of Resident 10's Nursing Weekly Summaries dated July 22, 2016, July 29, 2016, August 12, 2016, August 19, 2016, August 27, 2016, and September 10, 2016, indicated the resident had no contractures or joint mobility limitations. During an interview on September 16, 2016, at 4:25 p.m., LVN 4 stated Resident 10 was able to straighten his legs before. LVN 4 stated that resident's family member used to exercise the resident's legs when she came to visit the resident. On September 19, 2016, at 12 p.m., the PT came to assess Resident 10's joint mobility status. The PT indicated in his report that the resident had minimal joint mobility limitation on the right shoulder, bilateral ankles, and moderate joint mobility limitation on bilateral hip and knees. PT recommended that the resident will be on the RNA program for AAROM on both upper extremities, and PROM on both lower extremities five times a week as tolerated. During an interview on September 19, 2016, at 12:50 am, PT stated the nursing staff did not inform him about Resident 10's admission (July 25, 2016). The PT stated that the resident did not have an initial joint mobility assessment status and recommendation for treatment exercises. During an interview on September 22, 2016, at 12:20 p.m., the MDS nurse stated PT does the initial joint mobility assessment, but the nursing staff had to inform PT for newly admitted residents. A review of the facility's undated General Restorative and Supportive Nursing Care policy and procedures indicated the following: - Each resident will be provided with an individualized restorative and supportive plan of care to allow the resident the highest degree of independence possible within their physical and mental capabilities; - Provide early detection and intervention when independence declines in order to prevent complications and maintain the resident at their highest level of functioning. - Provide range of motion to maintain joint mobility, prevent contractures or prevent further deterioration and complications of limited ROM. According to the facility's undated policy and procedures for Joint Mobility Assessment indicated, that all residents will be assessed for joint mobility limitations upon admission. The facility staff failed to assess Resident 10's joint mobility status upon admission as indicated in the facility's policy and procedures. This resulted in resident not receiving necessary exercises to prevent development of contractures to resident's right shoulder, bilateral ankles, and moderate joint mobility limitation on bilateral hip and knees. The above violation had a direct or immediate relationship to the health, safety, and/or security of Resident 10. |
| 940000076 |
ROYAL OAKS CARE CENTER |
940012783 |
B |
29-Nov-16 |
K52711 |
15309 |
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. The facility failed to provide the necessary care for one of three sampled residents (Resident 1) by failing to: 1. Conduct an interdisciplinary team (IDT, a group consisting of the head of the different departments who work together to discuss a resident's care) care conference to address change in resident's behaviors, 2. Determine the type and frequency of resident supervision and provide the needed supervision based on the assessed resident's needs, 3. Monitor effectiveness of interventions, and 4. Review and revise the care plan. These deficient practices made it possible for Resident 1 to wander into the female residents' room and exposed himself. The exposure resulted in emotional stress to Residents 2 and 3. As a result of Resident 1's exposure, Resident 2 cried for a couple of hours, had bad dreams, became scared and stated that she did not feel safe in the facility. Resident 3 stated that she felt angry. On 4/19/16, at 10:25 a.m., the Department of Health received a complaint regarding a resident that goes to residents? rooms, exposing himself and intimidating residents. A review of Resident 1's Admission Record indicated that Resident 1 was readmitted to the facility on XXXXXXX with diagnosis of schizophrenia, a mental condition that causes both a loss of contact with reality (psychosis) and mood problems (depression [persistent feeling of sadness, loss, anger, or frustration that interfere with everyday life] or mania [hyperactivity]). A review of Resident 1's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 3/15/16, indicated Resident 1 usually understood others and was able to make self-understood. The MDS indicated that Resident 1 required supervision to limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) from staff with activities of daily living. A plan of care for schizophrenia manifested by hearing voices, wandering, and physically aggressive was developed for Resident 1 on 3/8/16. The staff interventions indicated to approach the resident calmly, speak in a calm voice, explain all procedures before the task, encourage to perform independent activities of daily living, attempt to refocus behavior to something positive when exhibiting inappropriate behavior, encourage resident to discuss interest and concerns, give medications as ordered, monitor behavior every shift, remove resident from stimuli that increase agitation or untoward behavior, psychiatric consult as needed, SSD (social service director) visits as scheduled, and encourage activity attendance of resident's choice and preference. A review of Resident 1's Change of Condition SBAR -Behavior Change, (SBAR, Situation-Background-Assessment-Recommendation, provides a framework for communication between members of the health care team), dated 4/5/16, at 9:30 pm, indicated that Resident 1 wandered into Room X. The Behavioral Change (Episodic) Care Plan of the SBAR indicated that Resident 1 was to be engaged in an activity, utilize a calm approach, redirection or diversion, modify environment as needed, monitor behavior and observe effectiveness of interventions. The Progress Note Updates of the SBAR indicated to provide frequent visual checks. A review of Resident 1's Change of Condition SBAR-Behavior Change, dated 4/18/16 at 6:15 pm, indicated Resident 1 was seen wandering into residents' rooms and trying to open locked doors. Resident 1 was difficult to redirect and follow commands. The Behavioral Change (Episodic) Care Plan of the SBAR indicated to engage Resident 1 in an activity, utilize a calm approach, redirection or diversion, modify environment as needed, monitor behavior and observe effectiveness of interventions. The Progress Note Updates of the SBAR indicated the physician was notified and an order was received to transfer Resident 1 to the acute hospital for psychological evaluation but no bed was available at the time. There was no documented evidence that the facility assessed and determined the type and frequency of resident monitoring/supervision based on Resident 1's behavior. There was no indication that Resident 1's care plans were reviewed for effectiveness. A review of Resident 1's Change of Condition SBAR-Mental Status Change, dated 4/20/16, at 3:05 pm, indicated Resident 1's increased irritability, agitation, paranoia (baseless suspicion of the motives to others), hallucinations (something the resident see, hear, feel, smell or taste that does not exist in reality), and restlessness. The Progress Note Updates of the SBAR indicated Resident 1 was transferred to the hospital for evaluation. During an interview on 5/6/16 at 8:42 a.m., Resident 3 (roommate of Resident 2) stated there were two incidents when Resident 1 came into their room (Room X). The first incident was around 10 p.m. (could not remember the date) and Resident 1 was standing against the wall by Room X Bed A. Resident 2 just came out of the restroom and told Resident 1 to get out of the room. Resident 1 closed the door instead but failed to leave the room. Resident 3 stated she went outside to get help by going through the adjoining restroom. Resident 3 stated the second incident happened a few days later after the first incident Resident 1 came into Room X. Resident 2 was in bed and told Resident 1 to go away. Resident 3 heard the conversation and pulled the curtain back and saw Resident 1 standing against the closet inside Room X. Resident 3 stated the 3 p.m. to 11 p.m. shift nurse came and took Resident 1 out of the room. Resident 2 went outside because she was so scared. On 5/6/16 at 8:50 a.m., during an interview, Resident 2 stated there were two incidents when Resident 1 came into their room (Room X). Resident 2 stated on the first incident when Resident 1 came into Room X, Resident 2 was coming out of the restroom approximately 10 p.m. (could not recall what day), Resident 1 was standing by the door inside Room X and then closed the door. Resident 1 dropped his pants and Resident 3 went out to get help. During that time, while Resident 3 was out to get help, Resident 2 was alone with Resident 1. Resident 2 stated she got scared. Resident 2 stated that the second incident occurred around evening time when Resident 1 came into Room X again and stood against the closet wall. Resident 2 stated she was screaming and telling Resident 1 to go away. A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility on XXXXXXX, with a diagnosis of diabetes (a metabolism disorder that affects the body's ability to use blood sugar resulting to high levels of sugar in the blood) with complications. A review of Resident 2's MDS, dated 2/5/16, indicated Resident 2 was able to make self-understood and understood others. Resident 2 required extensive (weight-bearing support) assistance with activities of daily living. A review of Resident 3's Admission Record indicated Resident 3 was readmitted to the facility on XXXXXXX, with a diagnosis of diabetes without complications. A review of Resident 3's MDS, dated 1/25/16, indicated Resident 3 was able to make self-understood and understand others. Resident 3 required limited assistance with activities of daily living. During an interview on 5/6/16 at 9:08, social worker (SW 1) stated Resident 1 had a behavioral problem of exposing his private part to females. On the second day (XXXXXXX) of Resident 1's first admission to the facility, he went into a residential front door and it took four people to get Resident 1 back to the facility. SW 1 stated Resident 1 hit her and knocked two of her teeth that became loose. Resident 1 was sent to the hospital for psychological evaluation. Resident 1 returned to the facility on XXXXXXX and was having behavior of exposing his private part. He exposed himself to the dietary supervisor (DS) and other females on several occasions during the 3 p.m.-11 p.m. and 11p.m.-7 a.m. shift. On 5/6/16 at 9:30 a.m., during an interview, the DS stated on 4/8/16, Resident 1 opened his jeans and exposed his private part to her as she walked towards Resident 1 in the hallway. The DS reported the incident to the director of staff development (DSD), SW 1, and business office staff. The staffs told the DS that "there had been incidents like these before, so just document the incident." On 5/6/16, at 12:20 p.m., during an interview and concurrent review of Resident 1's clinical record, the director of nursing (DON) stated that, "Frequent visual check is constant monitoring of the resident especially those with behavior problem. We do care plan upon significant change of condition." During the same interview and concurrent review of Resident 1's record, the DON stated, "We only have 72 hours monitoring after the incidents and we document in the nursing notes every shift." The DON stated they documented when there was a behavioral episode that occurred, using tally marks to determine Resident 1's frequency of behavior such as when nurses caught Resident 1 going into other residents' rooms. The DON stated there was not really any change in Resident 1's behavioral care plans. The DON stated Resident 1's care plans did not indicate any intervention regarding the type and frequency of supervision. On 5/6/16 at 1:30 p.m., during a follow up interview, Resident 2 stated she did not feel safe in the facility and stated she had been having bad dreams. During an interview on 5/6/16 at 1:51 p.m. and concurrent review of Resident 1's record, the Minimum Data Set nurse (MDS 1) stated Resident 1's daughter never showed up for IDT care conference. MDS 1 stated if the resident's family does not come and the resident could not participate in IDT care conference, they still do IDT care conference. MDS 1 was unable to find documented evidence of Resident 1's IDT care conference. During an interview on 5/6/16 at 2:15 p.m., and concurrent review of Resident 1's record, the DON stated there was no IDT care conference conducted for Resident 1 for behavioral incidents. Resident 1 should have had an IDT care conference conducted with or without Resident 1's family because of his inappropriate sexual behaviors. On 5/6/16 at 3:19 p.m., during a follow up interview, Resident 3 stated Resident 2 got scared and cried. Resident 2 remained and stayed in her room and did not want to go out because she was afraid of seeing Resident 1. During an interview on 5/6/16 at 3:30 p.m., the registered nurse (RN 1) stated Resident 2 was "more shaken" and scared; very upset and cried for a couple of hours during the incident of 4/18/16 incident. During an interview on 5/6/16 at 4:17 p.m., and review of Resident 1's record, the DON stated that Resident 1 was monitored hourly for 72 hours between 4/5/16 to 4/7/16 (after 4/5/16 incident) and 4/18/16 to 4/19/16 (after 4/18/16 incident). The DON stated there was no documentation indicating supervision or monitoring was done between 4/8/16 to 4/17/16 to address Resident 1's sexual behavioral history. A review of the Hourly Checklist (72 hour monitoring record) of Resident 1's whereabouts indicated the following: 1. From 4/5/16, starting at 7 p.m. to 4/7/16, at 6 am, a total of 35 hours out of 72 hours. 2. From 4/18/16, starting at 6 p.m. to 4/19/16, at 3 am, a total of 22 hours out of 72 hours. 3. There was no monitoring conducted for Resident 1 in skilled Nursing facility while he was waiting for a bed in the acute hospital for psychological evaluation until the resident was transferred on 4/20/16 at 4 pm. A review of the facility policy and procedure titled, "Safety and Supervision of Residents" revised December 2007 indicated: 1. Resident-oriented approach to safety: 2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. 3. Implementing interventions to reduce accident risks for hazards shall include the following: a. Communicating specific interventions to all relevant staff b. Assigning responsibility for carrying out interventions c. Providing training, as necessary d. Ensuring that interventions are implemented and e. Documenting interventions 4. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions c. Modifying or replacing interventions as needed and d. Evaluating the effectiveness of new or revised interventions 5. Systems approach to safety: 6. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 7. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in resident's condition. A review of the facility policy and procedure titled, "Behavior Assessment and Monitoring," revised April 2007 indicated monitoring: if the resident is being treated for problematic behavior or mood, the staff and physician will obtain and document ongoing reassessments of changes (positive or negative) in the individual's behavior, mood, and function. A review of an undated facility' s policy and procedure titled, "Care Plans" indicated the following: 1. Assess the resident upon admission and initiate a plan of care for the key problems or possible problems identified. 2. All goals will be measureable 3. Add changes to the resident's status as they occur. Therefore, the facility failed to provide the necessary care for Resident 1 by failing to: 1. Conduct an interdisciplinary team care conference to address change in resident's behaviors, 2. Determine the type and frequency of resident supervision and provide the needed supervision based on the assessed resident's needs, 3. Monitor effectiveness of interventions, and 4. Review and revise the care plan. These deficient practices made it possible for Resident 1 to wander into the female residents' room and exposed himself. The exposure resulted in emotional stress to Residents 2 and 3. As a result of Resident 1's exposure, Resident 2 cried for a couple of hours, had bad dreams, became scared and stated that she did not feel safe in the facility. Resident 3 stated that she felt angry. The above violations jointly, separately, or in any combination had a direct or immediate relationship to Residents 1, 2 and 3?s health, safety, or security. |
| 940000076 |
ROYAL OAKS CARE CENTER |
940013011 |
A |
1-Mar-17 |
SF1H11 |
14522 |
F367 ? 42 CFR 483.35(e) Therapeutic Diets
Therapeutic diets must be prescribed by the attending physician.
On August 28, 2015, at 8:45 a.m., an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care.
Based on observation, interview, and record review, the facility failed to ensure residents with swallowing problems were provided with thickened liquids by failing to:
1. Provide Resident 2 with a pitcher containing nectar thickened water(a mechanically altered liquid that is as thick as a milkshake that pours in a continuous stream without "breaking" into drops), at the bedside as ordered by the physician and in accordance with the plan of care.
2. Provide Resident 3 with a glass of nectar thickened milk as ordered by the physician.
3. Ensure two of the three dietary aides, Dietary Aide 1 and 3, who prepared the liquids with thickened consistencies, received training on correct measurement of the thickener and preparation of thickened liquids. There were seven residents (Resident 2, 3, 4, 5, 6, 7, and 8) in the facility with difficulty swallowing and who required thickened liquids.
4. Ensure two of the three dietary aides, Dietary Aides 1 and 3, who were assigned to prepare the nectar thickened liquids, understood the written instruction on how much thickener to add to liquids, such as water, milk, and juice.
5. Ensure a certified nursing assistant (CNA 1) checked the consistency of water before providing the pitcher of water at Resident 2's bedside.
6. Ensure a certified nursing assistant (CNA 2) and a licensed vocational nurse (LVN 1) checked the consistency of milk before providing Resident 3 with a glass of milk on the lunch tray.
These deficient practices had a potential to result in choking and aspiration pneumonia (an inflammation/infection of the lungs that occurs when foreign matter is inhaled into the lungs), which could lead to difficulty breathing, hospitalization, administration of antibiotics, and sepsis (a life threatening complication of an infection) for seven of the seven residents with swallowing difficulties, which required them to have liquids with thickened consistency.
On August 28, 2015 at 10 a.m., during the tour of the facility, Resident 2 was observed lying on a low bed and reaching his arms toward the side of the bed. A sign above the head of the bed indicated "Thickened Liquids Only." The certified nursing assistant (CNA 1) who was present at the time, removed the lid from the resident's pitcher. The pitcher contained regular (un-thickened) water.
During a concurrent interview, CNA 1 stated that the water pitcher contained regular water. CNA 1 stated the water in the pitcher was supposed to be thickened and that she had forgotten to check the water prior to placing the pitcher at the resident's bedside. CNA 1 removed the pitcher containing un-thickened water at the resident's bedside, and obtained a pitcher of nectar-thickened water and provided it to the resident.
On August 28, 2015 at 1 p.m., during an observation, Resident 3 was lying in bed while being fed lunch by a family member. A sign, which indicated "Thickened Liquids Only," was placed at the head of the resident's bed. A four-ounce glass of milk was on the meal tray. The glass of milk was covered with plastic wrap with a letter "N" (for nectar thickened consistency) written on the wrap but the milk had a regular (un-thickened) liquid consistency. CNA 2 inspected the resident's glass of milk and stated, "It's too thin. It should be thick. He has a problem swallowing. It should be thick so he doesn't choke." The licensed vocational nurse (LVN 1) also inspected the resident's glass of milk and stated the milk's consistency was too thin, and that the resident's glass of (un-thickened) milk would be replaced right away with a glass of nectar-thickened milk.
On August 28, 2015 at 1:05 p.m., Dietary Aide 1 and the dietary service supervisor (DSS) were interviewed. Dietary Aide 1 stated she prepared glasses of milk for the meal trays, which included the glass of milk served to Resident 3. Dietary Aide 1 stated she assisted in setting up the trays. When asked how much thickener was added to the four-ounce glasses of milk for nectar-thick consistency, Dietary Aide 1 replied she added one teaspoon of thickener to each glass. Dietary Aide 1 stated if more than one teaspoon was added, the milk became too thick, and that would be difficult for the residents to swallow. When Dietary Aide 1 was asked what "nectar- thick" meant, she replied, "It means it's supposed to be thicker."
During a concurrent interview, the DSS stated the kitchen staff followed a chart, which indicated how much thickener was to be added to water, juice, or milk. The DSS stated that sometimes a thickened drink needed to be shaken, due to the settling nature of the thickener at the bottom of the glass. The DSS stated the glass of milk, which was given to Resident 3, needed more thickener.
During the interview, the DSS showed a chart titled, "Resource Thicken Up, Instant Food and Drink Thickener," which indicated how much thickener was to be added to four fluid ounces of liquid for nectar, honey, and pudding consistencies. The column on the chart titled, "Nectar," indicated "1T + 1 tsp" (one tablespoon plus one teaspoon) for skim and/or one (1) percent (%) milk, and whole and/or 2% milk.
On August 28, 2015 at 1:10 p.m., when Dietary Aide 1 was asked what the measurement "1T + 1 tsp" meant, she pointed to the section which indicated "1 tsp" and stated, "I just look at that part." Dietary Aide 1 was asked what she used to measure the thickener. Dietary Aide 1 obtained a set of measuring spoons and stated, "I use this one," pointing to the teaspoon.
During a concurrent interview, the DSS stated Dietary Aide 1 was hired three to four months ago. The DSS stated she had given an in-service (education) in the past to the kitchen staff about preparation of thickened liquids. When asked if the dietary staff personnel files contained documentation of the training the staff received, the DSS stated "No." When asked if she oversaw the food preparation, the DSS stated, "Sometimes, yes."
On August 28, 2015 at 2:55 p.m., during an interview, Dietary Aide 3 stated she worked at the facility for five years. When questioned how much thickener she added to four ounces of milk, Dietary Aide 3 obtained the set of measuring spoons, then pointed to the teaspoon and stated, "I use one of these for four ounces."
On August 28, 2015 at 3 p.m., the DSS was asked to provide documented evidence of in-services provided to the staff about the preparation of thickened liquids. The DSS showed the surveyor a copy of an in-service, dated August 28, 2015, no time indicated, regarding how to use thickener according to consistency, and the difference between a tablespoon and teaspoon. The in-service was signed by Dietary Aide 1, Dietary Aide 2, Dietary Aide 3, and the evening cook. There was no documented evidence to indicate that the DSS provided in-services to the facility staff members regarding the preparation of thickened liquids over the past one year. The DSS also failed to show that an in-service about thickened liquids was provided to the facility staff members.
A review of the facility's policy, titled, "Nutrition Care," dated 2012, indicated "Thickened foods and liquids are provided to residents/patients with swallowing disorders to ensure a safe consistency for adequate nutrition and hydration, and to decrease the probability of aspiration. The appropriate consistency should be determined by the speech language pathologist, and ordered by the physician...The facility will determine whether nursing and/or dietary will thicken the liquids, of if pre-thickened products will be used. Manufacturer's instructions will be followed when using thickening agents, to provide the ordered consistency of liquids."
A review of Resident 2's clinical record, indicated the resident was a 55-year-old male, who was initially admitted to the facility on XXXXXXX 2010, and re-admitted to the facility on XXXXXXX 2012, with diagnoses that included stroke (a brain attack when there is poor blood to the brain resulting in cell death), dysphagia (difficulty swallowing), and glaucoma (a condition that causes damage to your eye's optic nerve and gets worse over time, and it's often associated with a buildup of pressure inside the eye) and blindness.
A review of Resident 2?s annual Minimum Data Set (MDS), a standardized assessment and care planning tool, dated May 20, 2015, indicated Resident 2 was severely impaired in his cognitive abilities, was unable to walk or talk, and was totally dependent on staff for all activities of daily living needs.
A review of Resident 2?s Physician Orders, dated February 1, 2014, indicated to provide Resident 2 with a pureed, nectar consistency diet.
A review of Resident 2?s care plan, titled, "Resident at Risk for Nutritional Problems Due to Dysphagia," dated May 15, 2015, indicated one of the approaches included to provide pureed diet with no added salt (NAS) and nectar-thick liquid as ordered by the physician.
A review of Resident 3's clinical record indicated the resident was an 85-year-old male, who was initially admitted to the facility on XXXXXXX 2014, and re-admitted on June 4, 2015, with diagnoses of confusion with possible dementia and blindness.
A review of Resident 3?s quarterly MDS assessment, dated June 8, 2015, indicated Resident 3 was confused, with short and long term memory problems, was unable to walk, and was totally dependent on staff for all daily living needs.
A review of Resident 3?s Physician Orders, dated June 4, 2015, indicated to provide Resident 3 with NAS diet, mechanical soft texture, with nectar-thick liquids.
A review of Resident 4's clinical record indicated the resident was an 86-year-old female, who was admitted to the facility on XXXXXXX 2014 and re-admitted on XXXXXXX 2015 with diagnoses that included Alzheimer's dementia (a progressive brain disease that slowly destroys memory and thinking skills and eventually even the ability to carry out the simplest tasks). The MDS, dated June 26, 2015, indicated the resident was cognitively impaired, totally dependent on staff for activities of daily living, and received mechanically altered diet (diet that requires change in texture of food and liquid, such as pureed food, thickened liquids).
A review of Resident 4?s physician's order, dated June 2, 2015, indicated to provide the resident with a regular diet, pureed texture (common foods that are blended to become smooth) and honey (liquid) consistency for oral gratification only.
A review of Resident 5's clinical record indicated the resident was a XXXXXXX year-old male, who was admitted on XXXXXXX 2014, with diagnoses that included hemiplegia (paralysis of one half of the body, including one arm and one leg) due to cerebrovascular accident (stroke). The MDS, dated July 21, 2015, indicated the resident was severely impaired in cognitive skills, was able to eat independently, and received mechanically altered (thickened) liquids.
A review of Resident 5?s physician's order, dated April 1, 2015, indicated to provide the resident with nectar thickened liquid.
A review of Resident 6's clinical record indicated the resident was a 68-year-old female, who was admitted on XXXXXXX 2015 with diagnoses that included diabetes (a metabolism disorder that affects the body's ability to use blood sugar). The MDS, dated August 21, 2015, indicated the resident was cognitively impaired, totally dependent on staff for activities of daily living, and received mechanically altered (thickened) liquids.
A review of Resident 6?s physician's order, dated August 14, 2015, indicated to provide the resident with nectar thickened liquids.
A review of Resident 7's clinical record indicated the resident was a XXXXXXX year-old female, who was admitted to the facility on XXXXXXX 2014 with diagnoses that included asthma. The MDS, dated July 21, 2015, indicated the resident was moderately impaired in cognitive skills, required supervision when eating, and received mechanically altered (thickened) liquid.
A review of Resident 7?s physician's order, dated October 24, 2014, indicated to provide the resident with nectar thickened liquid.
A review of Resident 8's clinical record indicated the resident was a 76-year-old male, who was admitted to the facility on XXXXXXX 2014 with diagnoses that included dementia. The MDS, dated July 21, 2015, indicated the resident was moderately impaired in cognitive skills and required supervision when eating.
A review of Resident 8?s physician's order, dated August 6, 2014, indicated to provide the resident with nectar (liquid) consistency.
The facility failed to ensure residents with swallowing problems were provided with thickened liquids by failing to:
1. Provide Resident 2 with a pitcher containing nectar thickened water (a mechanically altered liquid that is as thick as a milkshake that pours in a continuous stream without "breaking" into drops), at the bedside, as ordered by the physician and in accordance with the plan of care.
2. Provide Resident 3 with a glass of nectar thickened milk as ordered by the physician.
3. Ensure two of the three dietary aides, Dietary Aides 1 and 3, who prepared the liquids with thickened consistencies, received training on correct measurement of the thickener and preparation of thickened liquids. There were seven residents (Resident 2, 3, 4, 5, 6, 7, and 8) in the facility with difficulty swallowing and who required thickened liquids.
4. Ensure two of the three dietary aides, Dietary Aide 1 and 3, who were assigned to prepare the nectar thickened liquids, understood the written instruction on how much thickener to add to liquids, such as water, milk, and juice.
5. Ensure a certified nursing assistant (CNA 1) checked the consistency of water before providing the pitcher of water at Resident 2's bedside.
6. Ensure a certified nursing assistant (CNA 2) and a licensed vocational nurse (LVN 1) checked the consistency of milk before providing Resident 3 with a glass of milk on the lunch tray.
These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 940000096 |
Royal Care Skilled Nursing Center |
940013162 |
B |
28-Apr-17 |
72ZN11 |
10306 |
42 CFR 483.12(b)(1)-(3)
?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,
42 CFR 483.12(b)(1)-(3), 483.95(c)(1)-(3)
(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95,
?483.95
(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in ? 483.12, facilities must also provide training to their staff that at a minimum educates staff on-
(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at ? 483.12.
(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property
(c)(3) Dementia management and resident abuse prevention.
Based on interview and record review, the facility failed to implements it?s abuse/neglect prevention, intervention, investigation, and reporting policies and procedures by failing to:
1. Promptly report to the facility Administrator and investigate the incident whereby, Resident 1 (a female resident) wandered inside Resident 2's room (a male resident). The incident, which occurred a couple of months prior to 1/9/17 (the date when the incident report was made), was reported by a certified nursing assistant (CNA 1) to a charge nurse. The abuse allegation was not reported to the administrator in accordance with the facility's abuse policy and procedures.
2. Monitor Resident 1's location every 30 minutes as indicated in the plan of care, initiated on 4/21/16, for the resident's wandering behavior.
3. Change Resident 1's or Resident 2's rooms to prevent reoccurrence of sexual contact, since the residents' rooms were one room apart from each other, and Resident 1 could easily wander to Resident 2's room.
As a result, the right of Resident 1 to be free from a sexual abuse was violated. Resident 1, who does not have the capacity to consent to engage in a sexual act, wandered into Resident 2's room on 1/9/17 and was observed performing oral (mouth) sex with Resident 2.
A review of Resident 1's Admission Record (Face Sheet) indicated the resident was an 87-year-old female, who was admitted to the facility on XXXXXXX15 with diagnoses that included dementia (a long term and often gradual decrease in the ability to think and remember).
A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 11/17/16, indicated that the resident's cognitive (thinking, reasoning, or remembering) skills for daily decision-making were severely impaired. The MDS indicated that the resident required extensive assistance from the staff with transfer, locomotion on and off the unit, dressing, toilet use and personal hygiene. The resident used a walker and wheelchair as mobility devices.
A review of Resident 1's care plan for the resident's wandering behavior (the resident is a wanderer) because the resident wanders aimlessly, significantly intruding on others? privacy and activities indicated that it was initiated on 4/24/16, reviewed on 9/22/16, and had a target goal date of 2/15/17. One of the goals indicated that the resident's safety will be maintained through the review date. The interventions included to monitor the resident's location every 30 minutes, and document the resident?s wandering behavior and attempted diversional interventions in a behavior log.
A review of Resident 1's Situation, Background, Assessment or Appearance and Request Form (SBAR, a framework for communication between members of the health care team about a resident's condition), dated 4/21/16 in the afternoon and without a specific time, indicated that the resident had a wandering behavior. There was no specific description of where the resident wandered.
A review of Resident 1's Progress Notes, dated 4/23/16, 4/24/16, 4/25/16, 4/26/16, and 4/27/16, 4/30/16, indicated that Resident 1 was being monitored for wandering behavior and the resident had episodes of wandering. The progress notes, dated 4/30/16 at 10:05 p.m., indicated that the resident had two (2) episodes of wandering into other residents' room.
During an interview, on 1/11/17 at 3:34 p.m., a certified nursing assistant (CNA 1) stated that Resident 1 wandered into Resident 2's room a couple months ago. CNA 1 stated that she removed Resident 1 from Resident 2's room and she reported the incident to the charge nurse.
A review of Resident 1's Neuropsychological Evaluation (a test to examine a variety of cognitive abilities, including speed of information processing, attention, memory, language, and functions, which are necessary for goal-directed behavior), dated 1/19/17, indicated that Resident 1?s advance dementia syndrome (a group of symptoms that consistently occur together) rendered her more vulnerable to the possibility of coercion or abuse, hence her behavior and activities should be closely monitored to prevent future involvement in compromising situation.
During an interview with the Administrator, on 1/11/17 at 5:52 p.m., with a concurrent review of Resident 1's medical record from 4/2016 to 1/9/17, the Administrator stated that he was unable to provide the documented evidence that Resident 1's location was being monitored every 30 minutes as indicated in the plan of care that indicated that "The resident is a wanderer ...wanders aimlessly, significantly intrudes on the privacy of others or activities," initiated on 4/24/16, and reviewed on 9/22/16, with a target goal date of 2/15/17."
During an interview with a registered nurse supervisor (RNS 1), on 1/12/17 at 11:10 a.m., RNS 1 stated she was the RNS on 1/9/17, for the 3 p.m. to 11 p.m. shift. RNS 1 stated that at 3:45 p.m., while doing her rounds, she entered Resident 2's room and talked to residents on bed 1 and bed 2. RNS 1 stated that she proceeded to bed 3 (Resident 2's bed) and saw Resident 1 performing oral sex with Resident 2. RNS 1 stated that she took Resident 1 out of the room and placed her on 1:1 monitoring.
During an interview with the director of nursing (DON), on 3/20/17, at 3:35 p.m., the DON stated that she was not aware that Resident 1 was found inside Resident 2's room by CNA 1 couple of months ago. The DON stated that there was no investigation done about this incident. The DON was unable to explain the reason why either the residents? rooms were not changed after the incident, since both rooms were one room apart from each other, and it was quite conceivable that Resident 1 could easily wander into Resident 2's room.
During an interview, on 1/11/17 at 3:30 p.m., Resident 2 stated that Resident 1 "just comes" into his room. Resident 2 declined to answer any further questions about the incident.
A review of Resident 2's Admission Record indicated that the resident was a 66-year-old male, who was readmitted to the facility on XXXXXXX12 with diagnoses that included schizophrenia (a long-term mental disorder characterize by a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation). A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/28/16 indicated that the resident was capable of daily decision-making.
A review of the facility's 12/2012 revised policy and procedures titled "Abuse prevention, Intervention, Investigation and Crime reporting policy," indicated that it is the responsibility of employees to promptly report to the facility Administrator, local ombudsman, and Sate Licensing and Certification immediately or as soon as practically possible within 24 hours of detection, any incident of suspected or alleged neglect or resident abuse from other residents ...Reports shall be thoroughly investigated in a timely manner. The policy and procedures under Identification indicated that the facility will monitor the adequacy of assessment, care planning, and monitoring of residents with needs or behaviors that may likely lead to conflict, altercation, abuse or neglect, such as: socially inappropriate or disruptive behaviors ...wandering into the rooms or personal space of other residents.
The facility failed to implements its abuse/neglect prevention, intervention, investigation, and reporting policies and procedures by failing to:
1. Promptly report to the facility Administrator and investigate the incident whereby, Resident 1 (a female resident) wandered inside Resident 2's room (a male resident). The incident, which occurred a couple of months prior to 1/9/17 (the date when the incident report was made), was reported by a certified nursing assistant (CNA 1) to a charge nurse. The abuse allegation was not reported to the administrator in accordance with the facility's abuse policy and procedures.
2. Monitor Resident 1's location every 30 minutes as indicated in the plan of care, initiated on 4/21/16, for the resident's wandering behavior.
3. Change Resident 1's or Resident 2's rooms to prevent reoccurrence of sexual contact, since the residents' rooms were one room apart from each other, and Resident 1 could easily wander to Resident 2's room.
The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1. |
| 950000046 |
ROYAL CREST HEALTH CARE |
950009552 |
A |
05-Nov-12 |
1TGK11 |
12103 |
F327 483.25 (j) The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.The facility failed to ensure that Resident 1 had sufficient fluid intake to prevent dehydration (excessive loss of body water) by failing to: 1. Provide sufficient fluid intake as assessed by the dietician to maintain proper hydration and health for Resident 1. 2. Fully assess the amount of fluid consumed by Resident 1 who was assessed as being at risk for dehydration due to advanced age, cognitive impairment and diuretic (Lasix) use.3. Notify the physician promptly when Resident 1 had diminished fluid intake and became drowsy.As a result Resident 1 had a delay in the provision of necessary care and treatment for dehydration and for acute renal failure treatment, a serious medical condition.On January 4, 2010, at 11 a.m., an unannounced visit was made to the facility to investigate a complaint regarding resident care and services. A review of Resident 1's admission information sheet indicated that the resident was a 97 year old male who was admitted to the skilled nursing facility (SNF) on November 30, 2009, with diagnoses that included congestive heart failure (CHF- condition in which the heart can no longer pump enough blood to the body), dementia, hypertension (high blood pressure), failure to thrive (state of decline characterized by gradual physical decline accompanied by lack of interest and a loss of willingness to eat or drink), and pressure ulcers.The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated December 13, 2009, indicated Resident 1 had problems with his short and long-term memory and was moderately impaired in his cognitive (mental) skills for daily decision-making, but was sometimes able to make his needs known and sometimes understood others. The resident required extensive assistance from the staff for most activities of daily living and was totally dependent on the staff for eating.Dehydration/fluid maintenance was triggered for care planning on the Resident Assessment Protocol Summary (RAPS) dated December 13, 2009. According to the RAP review, the risk factors and conditions associated with dehydration included: the use of diuretics, moderately/severely impaired decision-making ability, communication problem, and presence of infection. According to the RAP Review, the facility was to proceed with care planning, to prevent problems associated with dehydration. A review of a care plan dated December 13, 2009, indicated the resident was at risk for dehydration related to the use of diuretics. The care plan goal indicated that the resident would be free from signs and symptoms of dehydration daily. The listed nursing interventions included: a. Provide adequate fluids as ordered. b. Offer fluid frequently. c. Monitor for signs and symptoms of dehydration.However, the care plan did not specify the necessary amount of fluid to be given to the resident per shift and did not indicate how the facility would monitor the amount of fluid provided to the resident every shift to ensure that the resident had sufficient fluids.A nutritional assessment progress note dated December 14, 2009, indicated that the resident was spoon-fed by the certified nursing assistant (CNA). The note further indicated that the resident's oral intake and weight would be monitored. A review of the resident's Nutritional Assessment dated December 21, 2009, indicated that the resident was 5 feet and 6 inches tall, weighed 224 pounds (lbs.), and based on his weight, required 2,359 cubic centimeters (cc's) of fluids per day. The resident was on a pureed diet.The physician's order dated December 1, 2009, indicated to administer Lasix (medication used to reduce the swelling and fluid retention caused by various medical problems) 20 milligrams (mg) daily for CHF. (Lasix is a medication that helps reduce the amount of water in the body. According to the Mosby?s Nursing Drug Reference 23rd Edition, Page 44, Nursing considerations in the use of diuretics include: ?assess:? intake and output daily to determine fluid loss;?electrolytes, potassium, sodium, chloride, include blood urea nitrogen, blood glucose, complete blood count, serum creatinine,?imbalances may occur quickly,?signs including drowsiness.) The medication administration record (MAR) dated December 1, 2009, to December 29, 2009, indicated that the resident received Lasix 20 mg every day at 9 a.m. The day and p.m. shift's nursing assistant daily flow sheet from December 1, 2009 through December 20, 2009, indicated that Resident 1 consumed 100% of his meals (fluids included on the tray) most of the time. However, further review of the flow sheet revealed that from December 21, 2009, through December 29, 2009, the resident had a decrease in his usual oral intake of 100% to a varying oral intake of between 20% and 40%. Additionally, the resident had refused his meals on December 21, 2009 and December 29, 2009.The review of Nurses? notes dated December 29, 2009, at 10 a. m., revealed that the physician was notified regarding the resident?s refusal to eat and sleep most of the time. The physician ordered a complete blood count (CBC- gives important information about the kinds and numbers of cells in the blood, especially red blood cells, white blood cells, and platelets) and a comprehensive metabolic panel (CMP - a blood test that measures your sugar (glucose) level, electrolytes (chemical compounds) and fluid balance, kidney function, and liver function).A review of the laboratory results dated December 29, 2009, at 12:35 p.m., indicated the following:1. Elevated levels of glucose 117 milligrams per deciliter (mg/dl), high, (normal range 65 to 99 mg/dl) 2. Sodium greater than 160 milliequivalent per liter (mEq/L), critically high, (normal range 135 to 145 mEq/L), 3. Potassium 7.6 mEq/L, critically high, (normal range 3.5 to 5.5 mEq/L), 4. Chloride of 114 mEq/L, high, (normal range 90 to 109 mEq/L), 5. Blood urea nitrogen (BUN) 132 milligram per deciliter (mg/dL), critically high, (normal range 7 to 23 mg/dL), 6. Creatinine of 6.7, high, (normal range 0.6 to 1.4 mg/dL).According to MedlinePlus Medical Encyclopedia (2012), abnormal blood chemistries such as elevated sodium, potassium, chloride, BUN, and creatinine levels are indicators of dehydration. Based on the laboratory test results of December 29, 2009, Resident 1?s blood osmolality, was 346 mOsm (milliosmols) /kg (per kilogram) H20 (of water). The normal range for blood osmolality is 285 mOsm/kg H20 to 295 mOsm/kg H20. According to Mosby?s Diagnostic and Laboratory Test Reference, Ninth Edition, Page, 682, ?osmolality increases with dehydration?A nurse's note dated December 29, 2009, at 4:45 p.m., indicated that Resident 1's physician was notified of the resident's abnormal laboratory results and the resident was ordered to be transferred to acute care hospital for further evaluation.On December 29, 2009, at 6:31 p.m., Resident 1 was transferred to an acute care hospital emergency room (ER). The review of the ER Resident report and agenda dated December 29, 2009, revealed that the resident was admitted with chief complaint of altered level of consciousness and was diagnosed with acute renal (kidney) failure, hyperkalemia (high potassium), hypernatremia (high sodium), and dehydration.On January 4, 2009, at 9:30 a.m., during a telephone interview, Resident 1's family member stated that she regularly visited the resident at the SNF. She stated that during her past visits from December 21, 2009, and until the resident was transferred to the hospital on December 29, 2009, she would always find the resident asleep and hard to arouse. According to the family member, the resident was too sleepy to respond or drink the fluid she would offer him. She stated that sleepiness was not normal for the resident. During an interview with licensed vocational nurse (LVN) 1 on January 4, 2010, at 1:10 p.m., she stated that Resident 1 would usually sleep intermittently during the day, but would respond when he was woken up. However, LVN 1 stated that a few (unspecified) days, before the resident?s transfer to the acute care hospital on December 29, 2009, the resident slept most of the time, did not eat or drink fluid as much as before and was harder to arouse. According to LVN 1, she notified the resident's physician on December 29, 2009.During an interview with certified nursing assistant (CNA) 1 on January 6, 2010, at 11:35 a.m., she stated that Resident 1 was asleep most of the time a few (unspecified) days, before he was transferred to the acute care hospital on December 29, 2009. CNA 1 stated that the resident only took sips of water because he was too sleepy to drink.A review of Resident 1?s licensed nurses? notes and progress notes, from December 21, 2009 to December 28, 2009, revealed no documented evidence to indicate that the resident was fully assessed for the amount of fluid consumed (monitoring of intake and output of fluid) daily when the resident?s intake of fluids had decreased. Additionally, there was no evidence that Resident 1 was provided with the required 2,359 cubic centimeters (cc's) of fluids per day as noted on the dietary assessment.Although the licensed nurse and the CNA identified that Resident 1 was more drowsy a few days before the resident?s transfer to the acute care hospital, there was no evidence in the licensed nurses notes or progress notes to indicate that the facility staff further assessed the resident for the actual amount of fluid intake or further assessed the resident to determine if the resident?s drowsiness could be a sign of dehydration. There was no evidence that the facility staff notified the physician promptly that the resident?s meal and fluid intake had started to diminished and that the resident had become drowsy. Instead, the licensed nurse waited a few days to notify the physician after the resident?s fluid intake had continued to diminish and the resident had become drowsy, which was a sign of dehydration. In addition, there was no documented evidence that the resident was provided alternative interventions or measures to ensure that the resident received the necessary fluids required to prevent dehydration from December 21, 2009, to December 28, 2009, during the time when it was hard to arouse Resident 1 to drink fluids. Furthermore, a review of the medication administration record (MAR) dated December 1, 2009, to December 29, 2009, revealed that the resident continued to receive Lasix 20 mg daily as ordered by the physician that had likely resulted in worsening the resident?s dehydration, despite period of somnolence (sleeping for unusually long periods, drowsiness) and decrease in fluid intake.The facility?s undated policy and procedure titled ?Hydration,? indicated that staff was to monitor every resident?s meal to assure that all fluids that are served is consumed, offer fluids of different types at 10 a.m., 2 p.m., 8 p.m., and at bedtime and document fluid consumed in the form provided, and monitor the resident for signs of dehydration and notify charge nurse for further evaluation. The facility failed to ensure a resident had sufficient fluid intake to prevent dehydration (excessive loss of body water) by failing to: 1. Provide sufficient fluid intake as assessed by the dietician to maintain proper hydration and health for Resident 1. 2. Fully assess the amount of fluid consumed by Resident 1 who was assessed as being at risk for dehydration due to advanced age, cognitive impairment and diuretic (Lasix) use.3. Notify the physician promptly when Resident 1 had diminished fluid intake and became drowsy.As a result, Resident 1 had a delay in the provision of necessary care and treatment for dehydration and for acute renal failure treatment, a serious medical condition.The above violations presented imminent danger that death or serious harm would result therefrom. |
| 950000060 |
ROYAL TERRACE HEALTH CARE |
950011504 |
B |
22-May-15 |
0SUD11 |
4858 |
1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. The following violation was identified during a recertification survey on June 20, 2013. Based on record review and interview, the facility failed to implement their policy and procedure regarding physical abuse by failing to: 1. Immediately report an allegation of abuse to the Department within 24 hours in accordance with State Regulations. The Admission Information Sheet indicated that Patient 1 was initially admitted to the facility on August 15, 2006 and re-admitted on March 31, 2011, with diagnoses that included cerebrovascular accident, hypertension, dementia, and paranoid schizophrenia.The Minimum Data Set (MDS) a comprehensive assessment dated April 13, 2013, indicated Patient 1 had no memory problem, clear speech, and was able to make herself understood and had the ability to understand others. The mood and behavior patterns indicated that the resident exhibited verbal behavior directed towards others such as threatening others, screaming at others and cursing at others. The MDS also revealed that Patient 1 required supervision with all her activities of daily living, which included walking, dressing, toilet use and personal hygiene.On June 20, 2013, at approximately 6:30 p.m., a family interview with Family member 1 was conducted. According to Family Member 1, Patient 1 called to inform her that her hands were "twisted by two male certified nurse assistants (CNA) during her shower,? on June 18, 2013, at around 1 p.m. During the interview, Family member 1 informed the Surveyor that her "aunt" does not remember the names of the two male CNAs. She also stated that as far as she knows, the resident was not hurt. She also stated that she had notified Employee 1 about the abuse incident on the same day and was told they will thoroughly investigate the alleged abuse. Family member 1 further stated that she was already told that the alleged abuse did not happen.During an interview with the Patient 1, who spoke in her native language, she stated she did not know the names of the CNAs but knew they worked on the three to eleven (3p.m. to 11p.m.) shift.On June 21, 2013, at 11 a.m., the surveyor interviewed Employee 2, and asked if the alleged abuse was reported to the State Licensing and Certification unit, the DON stated: "No."Employee 2 further stated that the facility had already investigated the alleged abuse and found the allegation unsubstantiated. Employee 2 stated that there was no investigation report, only nursing notes written in the resident's clinical records. Employee 2 added that Employee 1, who was the Abuse Coordinator, was also aware of the incident before he went on personal leave that started on June 20, 2013.On June 21, 2013, at 11:50 a.m., Patient 1 was transferred to the acute hospital for further evaluation. During an interview with Employee 3, she stated Patient 1?s physician wanted Patient 1 to be seen in the acute hospital due to possible sepsis. On June 21, 2013, at 12 p.m., a review of the facility's undated policy and procedures, titled, " Reporting Abuse to facility Management, " indicated the following: " when an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse is reported, the facility administrator, his /her designee, will notify the following persons or agencies of such incident: a. the State licensing agency responsible for surveying/licensing the facility; b. the local/ State ombudsman .... notices to the above agencies/individuals may be submitted via US mail, special carrier, fax, e-mail or by telephone. Such notices will include, as a minimum: name of the resident, number of the room in which the resident resides, the type of abuse that was committed (examples are verbal, physical, sexual, neglect, etc.), the names of all the persons involved in the alleged incident and what immediate action was taken by the facility.Another interview was conducted with Employee 2 on June 22, 2013, at 11 a.m. Employee 2 stated that the she acknowledged that the alleged abuse should have been reported to the Department. During the exit conference the DON still did not report the alleged abuse incident to the Department. On June 22, 2013, at 2:42 p.m., the facility faxed a written report of the alleged incident that happened on June 18, 2013, four days after the incident.The facility failed to implement its abuse policy and procedure by failing to immediately report an allegation of abuse to the Department within 24 hours in accordance with State Regulations. These violations had a direct relationship to the physical, mental, and psychosocial well-being of Patient 1. |
| 950000260 |
ROYAL OAKS MANOR - BRADBURY OAKS |
950012031 |
A |
03-Jun-16 |
XQPH11 |
8982 |
CFR 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. CFR 483.25 (l) Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.On 9/4/15, at 1 p.m., an unannounced visit was conducted to investigate a complaint alleging Resident 1 received on 8/1/15, an over-dose of Methadone (narcotic to treat pain) and Ativan (a sedative to treat nervousness), by two nurses during the same shift.Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and failed to ensure Resident 1, who received routine Ativan and Methadone medications, was not administered duplicated doses on 8/1/15 by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) documented the administration of the medications Ativan and Methadone soon after their administration before going out on a break. 2. Ensure LVN 1 implemented the facility?s policy on Medication Administration to record the administration on the resident's Medication Administration Record (MAR) following the medication being given and in no case should the individual who administered the medication report off-duty, without first recording the administration of any medication.As a result, LVN 2 administered duplicated doses after 45 minutes causing Resident 1 to be over-sedated, exhibiting side effects including difficulty to arouse, garbled speech, drooling from mouth, and too drowsy to eat. A review of Resident 1's medical record indicated a re-admission to the facility dated 6/7/13, with diagnoses including vascular dementia (condition which damages the brain's blood vessels, reducing ability to supply brain with the amounts of nutrition and oxygen it needs to perform thought processes effectively), back pain, insomnia (disorder characterized by difficulty falling and/or staying asleep), and depressive disorder (an illness which involves sad mood and thoughts).A review of the resident's Minimum Data Set (MDS - standardized assessment and care planning tool) dated 5/23/15, indicated Resident 1 had impaired cognition and communication, had behavioral symptoms of agitation, and required supervision with transfers and toilet use.A physician?s order, dated 7/14/14, indicated Ativan 1 milligrams (mg) orally twice a day (2 p.m. and 10 p.m.) for anxiety manifested by aggressive behavior towards others. Another physician?s order dated 1/14/15 indicated Methadone 7.5 mg orally every eight hours (6 a.m., 2 p.m., and 10 p.m.) for pain (back pain). A care plan dated 7/2/15, developed for Resident 1?s behavioral symptoms related to anxiety and pain (severe pain to her back), had a goal for the resident to respond cooperatively resulting in the lowest daily maintenance dose of psychotropic medication (affect the mind, behavior, and emotions). The care plan intervention/action included to administer the Ativan as ordered.A review of the Pharmacist's Medication Regimen Review dated 7/22/15 indicated Resident 1 received Ativan 1 mg twice per day since 10/2014. The pharmacist recommended to evaluate the current dose of Ativan and to consider a gradual taper to ensure Resident 1 received the lowest possible effective/optimal dose. The medical record had no evidence the pharmacist's recommendations were addressed and relayed to the physician.The Controlled Drug Record - Individual Patients Narcotic Record dated 8/1/15, indicated LVN 1 administered Resident 1 Ativan 1 mg and Methadone 7.5 mg at 10 p.m. and LVN 2 administered Resident 1 Ativan 1 mg at 10 p.m. and Methadone 7.5 mg at 10:45 p.m. The Ativan and Methadone were given twice (duplicated doses) by LVN 1 and LVN 2 within 45 minutes. On 9/4/15, at 2:01 p.m., during an interview, the director of nursing (DON) stated LVN 1 called her the night of 8/1/15 and informed her she administered Methadone 7.5 mg and Ativan 1 mg to Resident 1 at 10 p.m. and did not document the administration of the medications in the Electronic Medication Administration Record (eMAR). The DON stated due to the ongoing agitation of Resident 1, LVN 2 also administered Methadone 7.5 mg and the Ativan 1 mg to Resident 1 at 10 p.m. and signed out the administrations in the eMAR. The DON stated, "The medication nurses are supposed to administer the medication and document administration in the eMAR and the Narcotic book right after the administration." On 9/4/15, at 3:48 p.m., during a telephone interview, LVN 1 stated she gave Resident 1 the Ativan and Methadone, signed them out in the narcotic book, gave LVN 2 the medication keys, and went on break. When LVN 1 got back to sign the medications out on the eMAR, she saw LVN 2 had signed out on the eMAR. LVN 1 stated, ?That was when we discovered the resident had been given two doses of the two medications.The on call physician ordered us to take the resident?s vital signs and monitor her. The resident slept all night." On 9/4/15, at 4 p.m., during an interview, Registered Nurse 1 (RN 1) stated when he came on duty the next morning (8/2/15), LVN 1 informed him of the double medication administration the prior night. RN 1 stated Resident 1 was very drowsy and he told the resident's paid care giver (PCG 1) to monitor the resident?s breathing due to the double dose of medications.RN 1 stated, "The medication administration procedure for our staff is pour, pass, and then sign." A review of the interdisciplinary notes dated 8/2/15, at 7 a.m., indicated Resident 1 was in the wheelchair at the nursing station noted drowsy, difficult to arouse, leaning her head and torso forward, the speech was garbled, and was drooling. The note also indicated Resident 1 was too drowsy to eat, and was assisted back into bed.The interdisciplinary notes dated 8/2/15 had a late entry by LVN 1 which indicated the DON instructed her (LVN 1) to complete a medication error form and notify the physician.A review of the Disciplinary Notice dated 8/6/15, indicated on 8/1/15 LVN 1administered the medications Methadone and Ativan to Resident 1 and did not sign the eMAR, and LVN 2 administered the same medications during the same shift. The Disciplinary Notice indicated this incident resulted in Resident 1 receiving double the ordered dose.A review of the facility's policy and procedure titled, "Psychoactive Drug Medication Administration General Guidelines," dated 9/2010, indicated the individual who administers medication, records the administration on the resident's MAR following the medication being given. The policy indicated in no case should the individual who administered the medication report off-duty, without first recording the administration of any medication.The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and failed to ensure Resident 1, who received routine Ativan and Methadone medications, was not administered duplicated doses on 8/1/15 by failing to:1. Ensure LVN 1 documented the administration of the medications Ativan and Methadone soon after their administration before going out on a break. 2. Ensure LVN 1 implemented the facility?s policy on Medication Administration to record the administration on the resident's MAR following the medication being given and in no case should the individual who administered the medication report off-duty, without first recording the administration of any medication.As a result, LVN 2 administered duplicated doses after 45 minutes causing Resident 1 to be over-sedated, exhibiting side effects including difficulty to arouse, garbled speech, drooling from mouth, and too drowsy to eat. The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 1. |
| 950000060 |
ROYAL TERRACE HEALTH CARE |
950012073 |
A |
17-May-16 |
LQJV11 |
8204 |
F333 - 483.25(m)(2). The facility must ensure that residents are free of any significant medication errors. F157 ? 483.10(b)(11) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in ?483.12(a). Based on interview and record review, the facility failed to ensure that residents are free of any significant medication errors. LVN 1 administered to Resident 1, medications that were not ordered for Resident 1. The medications belonged to the roommate (Resident 2). The facility failed to notify the physician timely regarding the medication error.Resident 1 was admitted to the acute hospital on 7/20/2014, was unresponsive and was not arousable despite pain stimulus, per admitting physician?s summary notes. Resident 1 was hospitalized for a total of eight (8) days from 7/20/14 to 7/28/14.A facility report to the Department dated 07/23/2014 indicated that LVN 1 administered the following medications to Resident 1 that belonged to Resident 2 on 7/19/14 at 4:45 pm:1) Famotidine 20 milligrams (mg) - "Famotidine works by decreasing the amount of acid the stomach produces. Famotidine is used to treat and prevent ulcers in the stomach and intestines. It also treats conditions in which the stomach produces too much acid. Before taking Famotidine, tell your doctor if you have kidney or liver disease. This medication may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be alert " (). 2) Baclofen 20 mg - "is a muscle relaxant and an antispasmodic. It is used to treat muscle symptoms caused by multiple sclerosis, including spasm, pain, and stiffness. Important information included that Baclofen may impair thinking or reactions. Common side effects include: Confusion, dizziness or lightheadedness, drowsiness, nausea, and unusual weakness, especially muscle weakness". (). 3) Primidone 125 mg - "Primidone is used for: treating and preventing seizures. Primidone is an anticonvulsant. It works by decreasing nerve impulses in the nervous system, which helps to reduce seizures. The precautions included to tell the doctor/pharmacist if you have any medical conditions, especially if you have a history of drug abuse or dependence, mental or mood problems (e.g., depression), or suicidal thoughts or behaviors; if you have liver problems, lung problems, or breathing problems "(). Record review indicated Resident 1 was a 63-yr-old female admitted to the facility on 3/1/14 with diagnoses that included Hepatic encephalopathy (the occurrence of confusion, altered level of consciousness, and coma as a result of liver failure; Cirrhosis of the liver (complication of liver disease which involves loss of liver cells and irreversible scarring of the liver), Diabetes Mellitus, Hypertension, Anxiety, and Depression. The Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 6/1/14, indicated the resident scored an 11 out of 15 in the cognition assessment, and required limited assistance with daily activities such as transfers, dressing, and toilet use. Resident 1 was alert and oriented and was able to make her needs known. A review of the nurses' notes dated 7/19/2014, at 4:45 pm indicated Resident 1 was given before dinner medications. The resident was given 3 medications in error: Baclofen, Famotidine, and Primidone. LVN 1 documented notifying the physician and that Resident 1 was placed on 72 hour observation for adverse side effects of medication. Resident has shown no change in the level of consciousness, no complaints of abdominal pain, shortness of breath, dyspnea (difficulty of breathing), or pruritus (itching). The nurses' notes dated 7/20/14, at 7:40 a.m., indicated Resident 1 was looking pale with a blank stare, had slow responses to verbal stimuli, had slurred (unclear) speech, had weak hand grips, and was unable to stand. The physician was called and ordered to transfer Resident 1 to the hospital. A review of the hospital records, physician admission notes, revealed the resident presented to the hospital on 7/20/14 at 9:45 a.m., was unresponsive and was not arousable despite stimulus from pain. She was hospitalized for a total of eight (8) days from 7/20/14 to 7/28/14.The hospital physician discharge summary dated 7/30/2014 for the period of 7/20/2014 to 7/28/2014 included the following information: "This 63-year-old female presented to the hospital with unresponsiveness. Resident does have a history of alcoholic liver disease as well as some opiate and benzodiazepine usage. She was not arousable despite stimulus from pain. The resident was admitted and care was centered around her altered level of consciousness. Neurology was called in as well as Nephrology. She was gently hydrated. She was given lactulose for the borderline high ammonia level. The resident gradually improved on all fronts and was able to be discharged back to the skilled nursing facility." During an interview on 8/4/14, at 2:10 p.m., Resident 1 stated she was unable to recall the events that occurred on the day she was transferred to the hospital. She stated she was told by staff upon her return to the nursing facility on 7/28/14 that she was unarousable and was not reacting to prompts and instructions before she was transferred to the hospital.During an interview on 8/5/14, at 3:10 p.m., LVN 1 stated that she did administer medications to Resident 1 that belonged to Resident 2 on 7/19/14, 4:45 pm. She stated she was just a part-time employee in the facility and the last time she worked was about a month prior to the incident, and that she was not too familiar with the residents. She stated she acknowledged her failure of not making sure she administered the correct medications to the correct resident.When asked if she immediately notified Resident 1?s primary physician of the incident, LVN 1 stated that she was instructed by two licensed nurses to write in the clinical records that the physician was notified. However, she stated that she did not call the physician, and assumed that either of the two licensed nurses notified the physician. She acknowledged her failure to notify the physician about the incident. LVN 1 stated she was not aware if any other staff notified the physician.During an interview on 4/14/16, at 3:15 p.m., Resident 1?s primary physician (Physician 1) stated that the facility usually called him if there were issues with any of his residents. He stated however, that he cannot recall being notified by any staff from the facility of an incident regarding any resident being administered wrong medications.A review of the facility's undated policy and procedures, regarding medication administration, General Guidelines, indicated:8). Residents are identified before medication is administered. Methods of identification include:a). Checking identification band b). Checking photography attached to medical record, if any c). Calling resident by name d). If necessary, verifying resident identification with other facility personnel . LVN 1 did not follow the policy and procedures. Furthermore, the facility failed to notify the physician timely regarding the medication error, causing a delay in appropriate medical treatment after a significant medication error.The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 950000260 |
ROYAL OAKS MANOR - BRADBURY OAKS |
950012311 |
B |
03-Jun-16 |
2WT711 |
5445 |
F314-Treatment/Services to Prevent/Heal Pressure Ulcers.Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Findings are: Based on observation, interview and record review, the facility failed to provide treatment and services for Resident A who had a high risk of developing pressure ulcers (area of skin damaged skin by staying in one position for too long) by failing to provide treatment to the left ankle, stage 2 pressure ulcer (superficial open sore in the upper layer of skin) for 3 treatment days and there was no weekly assessment for the week of October 15, 2013. As a result of these deficient practices, Resident A's pressure ulcer increased in size. During an interview, the director of nursing (DON), on October 25, 2013 at 12:11 p.m., stated Resident A's pressure ulcer to the left ankle was acquired in the facility. A review of Resident A's clinical record indicated the resident was a 94-year-old male who was admitted to the facility on December 19, 2010, with diagnoses that included presence of dementia (decreased intellectual functioning that interferes with normal life functions), chronic pain, and depression (medical illness that causes a persistent feeling of sadness and loss of interest).According to the MDS (a standardized assessment and care planning tool) dated August 28, 2013, Resident A was sometimes able to understand and be understood by others, required extensive assistance in repositioning while in bed and in performing activities of daily living (ADLs). The MDS indicated the resident was at risk of developing pressure ulcers and that the resident had one or more unhealed pressure ulcers at Stage 2. The assessment indicated the use of application of dressings to the pressure ulcer. A review of Resident A?s Skin Condition Identification and Weekly Progress Notes dated October 15, 2013, indicated the resident had a left outer ankle pressure ulcer, however, the assessment was not done. The last assessment done was dated October 8, 2013 and the pressure ulcer measured 0.4 centimeters (cm) in length by 0.4 cm in width. A review of the physician orders dated July 23, 2013, and the Treatment Record for October 2013, indicated a treatment every third day to apply a Duoderm (a patch that provides a healing environment for wounds) patch to the left ankle. For October 7, 2013, October 10, 2013 and October 13, 2013, the treatments were not documented as done. The LVN/treatment nurse, on October 25, 2013 at 1:18 p.m., reviewed the clinical record and acknowledged the treatments for October 7, 2013, October 10, 2013 and October 13, 2013, were not documented as done. The weekly assessment for the pressure ulcer for October 15, 2013, was not done. On October 25, 2013 at 1:30 p.m., during a skin assessment conducted in the presence of LVN/treatment nurse and CNA 1, the LVN/treatment nurse removed the Duoderm patch dated October 22, 2013, and it revealed a circular wound to the left ankle. The LVN/treatment nurse described the open wound as a Stage 2 (partial thickness skin loss involving epidermis, dermis, or both- the ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater) that measured 0.8 cm in length by 0.5 cm in width. The LVN stated the pressure ulcer had increased in size since the last measurement done on October 8, 2013. On October 28, 2013 at 2:20 a.m., during an interview, the DON stated she was aware of the concerns with Resident A's treatments and weekly assessment not being done for October 15, 2013. The resident went ten days (From October 15, 2013 to October 25, 2013) without getting the appropriate treatment for the pressure ulcer. The facility policy and procedure titled "Skin Protocol" dated December 11, 2011, indicated the treatment nurse is to carry out the physician order for the wound care at prescribed frequencies. In addition, the weekly skin assessment on the resident's wound will be conducted and documented and stage 2 wounds that are not healing with the physician order will be referred to the wound care clinic. There was no evidence that the facility staff followed the facility skin protocol to provide the resident with the physician treatment order, weekly assessment and failed to identify the emergence of a Stage 2 wound and get a referral to the wound care clinic of a stage 2 pressure ulcer to obtain orders for treatment to promote healing of the pressure ulcer. The facility failed to provide the treatment and services for Resident A who had a high risk of developing pressure ulcers (area of damaged skin by staying in one position for too long) by failing to provide treatment to the left ankle stage 2 pressure ulcer (superficial open sore in the upper layer of skin) for 3 treatment days and the weekly assessment for October 15, 2013 was not done. As a result of these deficient practices, Resident A's pressure ulcer increased in size: from a pressure sore measuring 0.4 cm by 0.4 cm to 0.8 cm by 0.5 cm. The above violation has a direct relationship to the health, safety or security of the resident. |
| 950000260 |
ROYAL OAKS MANOR - BRADBURY OAKS |
950012334 |
A |
18-Jul-16 |
2WT711 |
9410 |
F323-Free of Accidents Hazard/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 findings are: Based on observations, record reviews, and interviews, the facility failed to provide an environment that is free from accident hazards by not implementing safety measures for Resident A. Resident A?s ongoing assessments were not done to determine whether the resident required the use of lower leg straps when using a mechanical standing lift, to ensure the safe transfer of the resident. For Resident A, a two person physical assistance was not provided when transferring the resident for toilet use with a mechanical lift, as indicated in the care plan and in the facility's Care Lift Program. As a result of these deficient practices, Resident A sustained injuries to toes on both feet during a fall while being transferred with a Sara (standing and raising aid) 3000 lift and suffered much anxiety and distress as indicated in his pleas to his wife to help him while they were transferring him with only one inexperienced CNA On October 25, 2013 at 1:30 p.m., during a skin assessment conducted in the presence of the LVN 1 (licensed vocational nurse) and CNA1 (certified nursing assistant), LVN/treatment nurse removed the Resident A?s black socks and there were multiple wounds observed on Resident A's toes of both feet and a bruise (purple discoloration area as a result of an impact with an object) that covered the dorsal (pertaining to the back part) of the left foot with moderate swelling. When asked if they knew what happened to the resident, they both stated on October 23, 2013, CNA 2 forgot to secure the resident's legs while using the Sara 3000 lift. As a result, the resident fell from the lift and hit his feet on the platform of the lift. A review of Resident A's clinical record indicated the resident was a 94-year-old male who was admitted to the facility on December 19, 2010, with diagnoses including dementia (decreased intellectual functioning that interferes with normal life functions), chronic pain, and depression (medical illness that causes a persistent feeling of sadness and loss of interest). According to the Minimum Data Set (MDS- a standardized assessment and care planning tool), dated August 28, 2013, Resident A was sometimes able to understand and be understood by others and required extensive assistance in toilet use with a two or more person physical assist. A review of the facility's Care Lift Program dated October 4, 2013, indicated to use the standing lift/Sara lift with a two to three person assist for Resident A. The activities of daily living (ADL) Flow Sheet dated October 2013, indicated on October 23, 2013 during the 7 a.m. to 3 p.m. shift, Resident A's mood was both calm and agitated. The resident's usual mood for the 7 a.m. to 3 p.m. shift from October 1, 2013 to October 22, 2013, was calm. The record area for toilet use on the flow sheet indicated on October 23, 2013, Resident A was totally dependent on staff with two person assist. During an interview with Resident A's wife/roommate on October 28, 2013, at 7:30 a.m., she stated her husband was dropped to the floor from the lift last week because the "new" CNA did not secure his legs. She further stated, "I knew they were going to hurt him, but I did not want to hurt her feelings by telling her to strap his legs." During an interview with CNA 2 on October 28, 2013, at 7:40 a.m., she stated she's been working in the facility since September 2013. When asked what happened on October 23, 2013, with Resident A, CNA 2 stated she forgot to use the straps on the lift for the resident's legs because he was so combative. Resident A's feet hit the floor during the transfer and the resident came down from the lift falling to his knees. During an interview with the RN (registered nurse) supervisor on October 28, 2013, at 8:44 a.m., she stated she was in the room assisting CNA 2 with Resident A?s transfer from the bed to the toilet on October 23, 2013, at an unspecified time. She left the room when the resident was placed on the toilet using the lift. When she returned to the room, 15 to 20 minutes later, to check on CNA 2, she saw Resident A off the toilet and kneeling on the lift. She then left the room to call for staff support to transfer the resident onto a total lift/Maxi lift, while CNA 2 stayed with the resident. On October 28, 2013 at 9:36 a.m., the DON (director of nursing) stated she was not aware of the accident with Resident A. The RN supervisor completed the incident report and reported to the DON the resident had bumped his toes. When asked what is the facility's policy when an accident is reported, she stated the resident is observed for unusual pain, monitored for 72 hours, the resident's physician is notified and X-rays are done. She stated that since Resident A's incident was not reported as an accident while using the lift, the facility's policy was not followed. On a subsequent interview with the RN supervisor on October 28, 2013 at 9:58 a.m., she stated she was so focused on Resident A's behavior and obtaining the correct treatment for the resident's wounds that she did not report the incident immediately to the DON or interview CNA 2 to inquire how the resident obtained the injuries to the toes on both feet. A review of the Nurse's Notes dated October 23, 2013, indicated during the morning ADLs, CNA 2 was trying to get resident ready for shower when the resident became combative. The note did not mention an accident occurred while the resident was on the lift. A subsequent nurse's note dated October 25, 2013, indicated Resident A stated the wounds hurt when they are touched. The abrasions sustained on the resident's toes from the accident as indicated on the nurse's notes, care plan for the wounds and physician orders dated October 23, 2013 were: 1. Right foot-3rd toe 2 centimeter (cm) x 1 cm, 4th toe 1.5 cm x 0.3 cm, 5th toe 1.5 cm x 0.7 cm and 1.6 x 0.5 cm. 2. Left foot-Great toe 0.6 cm x 0.2 cm, 2nd toe 1.3 cm x 1 cm, 3rd toe 0.6 cm x 0.5 cm. On October 28, 2013 at 1:15 p.m., CNA 3 and CNA 4 were observed transferring Resident A from the wheelchair to the bed. Resident A was calm, physically holding onto the lift throughout the transfer and stating, "Ouch you're hurting me, that's high enough, you're hurting me, please let me down, mother dear, please, don't let them hurt me." After the resident was rested on the bed, his shoes were removed and the resident complained of pain to his feet. A review of the Jobsite Safety Body Mechanics-Safety Resident Lift and Transferring in-service training sheets indicated they were conducted on March 12, 2013, March 13, 2013 and June 3, 2013. The training in- services were conducted three months prior to CNA 2's hire date. A review of the care plan for transfer dated September 17, 2013, indicated an intervention to utilize a mechanical lift device with two person assist. There was no evidence that CNA 2 was provided with in-service training in the use of the standing lift. There was no evidence the RN supervisor assessed the resident on October 23, 2013, to determine whether the resident required the use of the lower leg straps of the standing lift to ensure the safe transfer of the resident. There was no evidence Resident A was provided a two person physical assistance throughout transferring the resident with a standing lift as indicated in the facility's Care Lift Program and care plan. According to the Operating and Product Core instructions for the Sara 3000 lift, an assessment must be made as to whether the patient requires the lower leg straps, and the patient's feet should always remain in full contact with the foot support. http://nursing.uchc.edu/safe_patient_handling/docs/Sara%203000%20Oper%20Instr.pdf The facility's policy and procedure revision date of August 2012, titled Incident Reporting System, indicated sentinel events include injury resulting from the use of equipment and must be reported on an incident report form. The facility failed to provide an environment that is free from accident hazards by not implementing safety measures for Resident A. 1. Failed to ensure Resident A?s, ongoing assessments were done to determine whether the resident required the use of lower leg straps when using a mechanical standing lift, to ensure the safe transfer of the resident. 2. Failed to provide two person physical assistance with a mechanical lift when transferring the resident to use the toilet, as indicated in the care plan and in the facility's Care Lift Program. As a result of these deficient practices, Resident A sustained injuries to toes on both feet during a fall while being transferred with a Sara (standing and raising aid) 3000 lift and Resident A was traumatized by much anxiety and distress as evidenced by his pleas to his wife not to let them hurt him while he was being transferred with the mechanical lift and only one inexperienced person assist. These violations presented either an imminent danger that death or serious harm would result or a substantiated probability that death or serious harm would result. |
| 950000060 |
ROYAL TERRACE HEALTH CARE |
950012707 |
B |
1-Nov-16 |
Z8J411 |
17752 |
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. Based on observation, interview, and record review, the facility failed to provide necessary care and services to Residents 5, 6, 9, 11 and 12. The facility staff failed to identify and treat the Norwegian scabies infestation which resulted in severe discomfort for the residents and put other residents at risk for scabies. A review of Resident 5's clinical records included a physician's order dated 11/17/15, at 4 p.m., indicating the resident was transferred to an acute hospital, for "generalized rash and pressure ulcer (open wound) to the coccyx." The Physician Report from the acute hospital dated 11/17/15, included an admitting diagnosis of "rash, scabies cannot be ruled out, empirically treat with Elimite?. (Elimite is a medication applied to the skin and used to treat scabies, a contagious skin infestation). Further review of the clinical records indicated Resident 5 was treated with Elimite the night before and was showered prior to transfer to the acute hospital on 11/17/15. The licensed nurses progress notes, from 11/23/15 to 1/4/16, did not reveal any documentation of the rash. However, the treatment records, from 11/3/to 1/4/16 indicated the resident was receiving Triamcinolone cream (to treat a variety of skin condition) two times a day. A review of the Admission Record of Resident 5 indicated the resident was readmitted to the facility on 11/18/15, with diagnoses that included pressure ulcers, hypertension (high blood pressure), dysphagia (difficulty swallowing) with gastrostomy tube feeding (a tube passed into a patient's stomach through the abdominal wall to provide a means of feeding), and cerebral infarction (ischemic stroke that occurs when the blood vessels that supply the brain are disturbed). The Minimum Data Set (MDS), a standardized assessment tool, dated 11/4/15, indicated Resident 5 had short and long-term memory problems, was severely impaired cognitive (mental) skills for daily decision-making, and required total assistance from the staff with activities of daily living. The licensed nurse's admission note dated 11/18/15 indicated the resident had "generalized body rash." The physician's order indicated treatment of generalized rash triamcinolone 0.1 % and leave open to air two times a day (BID) for 14 days then re- evaluate. On 1/4/16, at 7:40 a.m., during an observation with LVN 4 present, Resident 5's hands were scaly and crusted. The upper body and legs, and entire body were covered with raised red papules (solid rounded growth that is elevated from the skin. Papules when scratched may open and become crusted and infected). Resident 5 was vigorously scratching these areas. During an interview at 7:45 a.m., LVN 4 stated Resident 5 was seen by a dermatologist (skin diseases specialist) on 12/10/15, and was diagnosed with severe drug eruption and dermatitis. LVN 4 also stated the dermatologist prescribed Triamcinolone cream (medication applied to skin to help relieve redness, itching, swelling and other discomfort caused by skin condition". On 1/5/16, at 9:30 a.m., the DON (Director of Nurses) was asked if she was aware of the resident's rash. She stated she did but she did not know the type of rash the resident had. The DON stated that she would notify Resident 5's physician right away. At 10 a.m., an interview with certified assistant (CNA 1) was conducted. CNA 1 stated Resident 5's roommates (6, 9, and 11) also had rashes and were itching. CNA 1 stated that Resident 5 had been itching for a month. Resident 6 (B bed) had the rash and itching for 3 weeks, Resident 9 (C bed) had the rash and itching for 3 weeks, and Resident 11 (D bed) had been itching for 3 days. CNA 1 also stated she too had been itching for 2 weeks and had seen her physician and was given anti-itch medication (Hydroxyzine- medication which helps treat the symptoms of allergies and allergic reactions, such as itching, sneezing and sniffling). On 1/5/16, at 10 a.m., the administrator and the DON were informed about the findings. The administrator arranged for an immediate Dermatology consultation. At 4 p.m., the DON stated the Dermatologist would see the residents in the evening. On 1/5/16, at 8:30 a.m. the DON stated that the result of the scraping was not ready yet. An interview with LVN 4 was conducted on 1/6/16, at 10 a.m. LVN 4 stated Resident 5 was sent to the Dermatologist clinic on 11/17/15, and was prescribed the Triamcinolone cream and Benadryl (medication for itching.) LVN 4 stated that he was not sure if a skin scraping (a test used to determine the presence of scabies) was performed. He also stated that there was no mention of isolation precautions. LVN 4 stated he did not know that the rash was scabies otherwise he would have taken action sooner. On 1/6/16, at 11 a.m., during an interview with the DON, she stated that there would be another dermatologist coming to the facility to perform skin scraping on all residents of the facility. On 1/7/16, at 7 a.m., the DON presented the Dermatologist consult notes dated 1/6/16, indicating that Resident 5 had a positive result for Norwegian scabies. According to Los Angeles County Department of Public Health, Acute Communicable Disease Control Program, July 2009 - version 3: Human scabies is caused by an infestation of the skin by the human itch mite. Some immunocompromised, elderly, disabled, or debilitated persons are at risk for a severe form of scabies called crusted or Norwegian scabies. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs and are very contagious to other persons. In addition to spreading scabies through brief skin to skin contact, persons with crusted scabies can transmit scabies indirectly by shedding mites that contaminate items such as their clothing, bedding, and furniture. Persons with crusted scabies should receive quick and aggressive medical treatment for their infestation to prevent outbreaks of scabies. The most common signs and symptoms of scabies are intense itching (pruritus), especially at night, and a pimple-like (papular) itchy rash. During a telephone interview with the dermatologist on 1/11/16, at 2:30 p.m., he stated that Resident 5 was positive for Norwegian scabies. The dermatologist stated that the condition had probably existed for a year or so and that this type of infection would occur in debilitated patients who were not being taken care of. The dermatologist also stated that the licensed nurses should have identified the patient's skin problem sooner; and that the resident should have received the appropriate treatment to prevent the outbreak. The facility's policy and procedure on "Skin Assessment", dated 4/2012, indicated: It is the facility's policy to check and assess resident ' s skin condition upon admission, once every shift, during shower and upon discharge to determine skin condition and assure that the appropriate treatment is implemented. The undated policy and procedure titled "Isolation Measures," indicated: Isolation procedures are designed to help prevent the spread of microorganisms among residents, visitors and personnel. Since the infecting agent (source) and the host factors are more difficult to control, the interruption in the spread of infection is directed at transmission and thus the utilization of special isolation measures. b. On 1/4/16, at 7:30 a.m., a review of the lists of residents receiving skin treatment indicated Residents 5, 6, 9 and 11 were being treated for skin rashes. Record review indicated Resident 6 was admitted to the facility on 6/24/15, with diagnoses that included diabetes mellitus (high sugar level in the blood and hypertension (high blood pressure) The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 10/7/15, indicated that the resident was able to understand others, able to make herself understood, and required extensive assistance with all of her activities of daily living. There was no documentation that skin rashes were present. During observations with LVN 4 on 1/5/16, at 9:30 a.m., Resident 6 was in bed, and stated that she was itching on her body. The resident had scattered multiple raised reddened papules and red pin point marks to bilateral arms, abdomen, back, and lower legs with itching to both arms, wrists, thighs and legs, chest and back areas (indicative of scabies infestation). According to LVN 4, the resident was also receiving treatment for the rash since 12/15. The nurses notes dated 11/18/15 indicated Resident 6 had "dermal rash with red color on upper back and right side of the body." The note indicated that the physician was made aware and new order was received for application of Triamcinolone 1% cream two times a day for 14 days, then re-evaluate. On 11/27/15, the staff received physician's telephone order to discontinue the treatment to the skin rash on right and left extremities, resolved. May apply hydrocortisone 1 % to right and left lower arm for itching two times a day for 2 weeks as needed (prn). On 12/2/15, there was another physician?s order to apply Triamcinolone to back and right side of the body. On 12/6/15, the physician ordered bacitracin (an antibiotic cream applied to skin) to apply to skin scratches for 7 days. On 12/16/15, an order for Triamcinolone 1 % cream to upper back, right side of the body rash was continued. Another physician's order dated 12/30/15 was received to cleanse rash on upper back, right side of body with soap and water, pat dry, apply Triamcinolone 0.1% cream and leave open to air two times for 14 days, then re-evaluate. Since 11/18/15, there was no documented evidence of a continuing assessment of the skin condition. On 1/5/16, at 1 p.m., during an interview with CNA (Certified Nursing Assistant) 1, she stated that Resident 6 has had the rash and itching for about three weeks. During an interview with DON and LVN 4 on 1/5/16, at 9:40 a.m. they both stated that scabies was not ruled out for Resident 6. LVN 4 stated that the physician had not seen and assessed the resident. He added that the CNAs would report to him about their findings, and then he would do his assessment and call the physician for orders. LVN 4 stated he did not know that it could be scabies. The DON stated that they do not have a system of tracking or surveillance of skin rashes and/or infections. According to Davis Drug Guide for Nurses, Ninth Edition, during Triamcinolone cream treatment the nurse should assess affected skin before and daily during therapy. Note the degree of inflammation and pruritus. Notify the physician or other health care professional if symptoms of infection (increased pain, erythema, purulent exudate) develop. (c) Resident 9 was admitted to the facility on 9/7/15, with diagnoses that included dysphagia (difficulty in swallowing), gastrostomy tube (G tube- an opening into the stomach and Alzheimer?s disease (a neurological disorder in which the death of brain cells causes memory loss and cognitive decline). A latest Minimum Data Set (MDS), dated 10/14/15, indicated the resident's cognitive skills for daily decision making were severely impaired, and was totally dependent on staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. An interview was conducted with CNA 2 on 1/5/15, at 9:45 a.m., CNA 2 stated she had observed Resident 9?s rash for about 2 weeks. She also stated that she had informed the treatment nurse about it. While CNA 2 provided care, Resident 9 was observed with raised papules on her arms, wrists, upper back, left knee and left foot. CNA 2 stated the resident cries whenever she tried to touch her. During a general observation with LVN 4 on 1/6/16, at 9 a.m., Resident 9 was lying in bed. Resident 9 was not inter-viewable but was making a lot of sounds. According to LVN 4, the resident was not able to state what she wants. He stated the resident was receiving treatment for a skin tear on the right arm but not for a skin rash. LVN 4 stated he was not aware of any of her skin rashes. On 1/5/16, at 9:45, the DON went to the resident's room to check on the rashes. During an interview, the DON stated she was not aware of Resident 9's rash. During record review with the DON and LVN 4 on 1/5/16, at 9:45 a.m., they were not able to find any documented evidence that Resident 9's rash and itching was assessed. The facility failed to assess Resident 9's skin condition resulting in no intervention/treatment. d. A review of the Admission Record of Resident 11 indicated the resident was admitted to the facility on June 14, 2014, with diagnoses that included paralysis agitans (progressive disorder of the nervous system that affects movement), hypertension (high blood pressure), diabetes mellitus (high blood sugar), and rhabdomyolosis (a condition in which skeletal muscle is broken down, releasing muscle enzymes and electrolytes from inside the muscle cells). The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated December 27, 2015, indicated the resident was able to understand others and able to make self-understood, and required extensive to total assistance with activities of daily living. During an interview on January 5, 2016, at 10 a.m., Certified Nursing Assistant (CNA) 1 stated that all four residents in room 11, including Resident 11, has a generalized body rash. CNA 1 stated Resident 11 had the body rash for about three days. During an observation on January 5, 2016, at 10:30 a.m., Resident 11 was observed sitting in a wheelchair in the activity room. CNA 1 brought the resident back to her room for a skin assessment. During the skin assessment, Resident 11 was observed with reddened papules (small solid rounded bumps rising from the skin that are each usually less than 1 in diameter) on bilateral hands, wrists, fingers, and ankles. A review of a nurse's note dated January 5, 2016, at 11 a.m., indicated the resident's physician was notified of the rash and new orders for a dermatology consult, skin scraping and contact isolation precaution were received. A review of a physician's order dated January 5, 2016, at 6:10 p.m., indicated the following orders for a diagnosis of dermatitis (inflammation of the skin) unspecified: a. Zyrtec (for allergy) 10 milligrams (mg) every morning for four weeks. b. Benadryl (allergy, cold symptoms) 25 mg every night at bedtime for four weeks. c. Clobetasol (topical to help redness and itching) 0.05% cream to be applied to rash twice a day for four weeks. d. Hibiclens (skin cleanser) 4% wash to be used all over body once a day for four weeks e. Permethrin 5% to be applied from neck down to toes and left for 12 hours then rinse. Repeat above once a week for four weeks. f. Ivermectin (treat infection caused by parasites) i.e. scabies, lies) 9 mg once a week for four weeks. During an interview on January 6, 2016, at 8:50 a.m., Resident 11 stated she has had the rash on her arms for about a month and complained of feeling itchy. The resident stated the staff applied cream on her body last night and gave her medications that made her feel better. During an interview on January 6, 2016, at 8:55 a.m., Licensed Vocational Nurse (LVN) 4 stated that the resident's rashes were first assessed and treated on January 2, 2016. However, a review of the clinical record with LVN 4 did not contain documentation that the resident's skin rashes were assessed and treated until January 5, 2016. e. A review of the Admission Record of Resident 12 indicated the resident was originally admitted on December 6, 2014, and was readmitted on January 10, 2015, with diagnoses that included chronic kidney disease, diabetes mellitus, and Parkinson's disease (a degenerative disorder of the central nervous system that belongs to a group of conditions called movement disorders). The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated December 16, 2015, indicated the resident was able to complete the brief mental status interview, understands others and able to make self-understood, and required extensive to total assistance with activities of daily living. During an interview on January 6, 2016, at 8:45 a.m., Certified Nursing Assistant (CNA) 2 stated that Resident 12 has a rash and has been scratching for about two weeks. CNA 2 stated she reported this to the charge nurse. On January 6, 2016, at 9:15 a.m., an assessment of Resident12's skin was done with Licensed Vocational Nurse (LVN) 4. During the skin assessment, Resident 12 was observed with scattered rash to bilateral upper arms and right flank area and some scratch marks. During an interview on January 6, 2016, at 9:16 a.m. LVN 4 stated he was not aware of the resident's rash and did not see the rash yesterday when they conducted a skin sweep of all residents in the facility. LVN 4 stated he would notify the physician and obtain treatment. The facility failed to provide the necessary care and services to Residents 5, 6, 9, 11 and 12 and failed to identify and treat the Norwegian scabies infection, which resulted in severe discomfort for the residents and put the other residents at risk for scabies. These violations had a direct relationship to the health, safety or security of the residents. |
| 950000060 |
ROYAL TERRACE HEALTH CARE |
950012710 |
B |
1-Nov-16 |
Z8J411 |
19301 |
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. Based on observation, interview, and record review, the facility failed to treat, detect and implement transmission-based precautions in addition to standard precautions, for Resident 5 who was confirmed positive for scabies, failed to prevent, control cross-contamination and assess skin rashes for Resident 5's roommates , Residents 6, 9, and 11 and for CNA 5 who provided care to these residents. a. A review of Resident 5's physician's order dated 11/17/15, at 4 p.m., indicated the resident was transferred to an acute hospital for "generalized rash and pressure ulcer to the coccyx (tailbone)." Resident 5's Physician's Report from the acute hospital dated 11/17/15, indicated one of the admitting diagnoses included "rash, scabies cannot be ruled out, empirically (based on observation or experience) treatment with Elimite (a medication applied to the skin and used to treat scabies, a contagious skin infestation)." Further review of the clinical records indicated Resident 5 was treated with Elimite the night before and was showered prior to transfer to the acute hospital on 11/17/15. Resident 5's was readmitted to the facility on 11/18/15, with diagnoses that included pressure ulcers (open wounds), hypertension (high blood pressure), dysphagia (difficulty swallowing) with gastrostomy tube feeding (a tube passed into a patient's stomach through the abdominal wall to provide a means of feeding, administer medications), cerebral infarction (blockage in the blood vessels supplying blood to the brain). A review of Resident 5's clinical record identified in the licensed nurse's admission note dated 11/18/15, the resident had "generalized body rash." The physician's order dated 11/18/15, indicated: cleanse generalized rash with soap and water, pat dry, apply triamcinolone 0.1 % and leave open to air two times a day (BID) for 14 days then re- evaluate. On 1/4/16, at 7:40 a.m., during an observation with LVN 4 Resident 5's hands were scaly and crusted. The resident's upper body and legs, and entire body were covered with raised red papules (solid rounded growth that is elevated from the skin. Papules when scratched may open and become crusted and infected). Resident 5 was vigorously scratching these areas. On 1/4/16, at 7:45 a.m., during an interview, LVN 4 stated Resident 5 was seen by a dermatologist (skin diseases specialist) on 12/10/15 and was currently being treated with triamcinolone cream (medication applied to skin to help relieve redness, itching, swelling and other discomfort caused by skin condition). On 1/5/16, at 9:30 a.m., the DON was asked if she was aware of the resident's rash. The DON stated that she did. However, she did not know the type of rash the resident had. The DON stated that she would notify Resident 5's physician right away. On 1/5/16, at 9:40 a.m., when asked for documented evidence of the facility's surveillance and tracking of scabies/rashes (program for early detection of infested patients and staff), the DON stated the facility did not have one. On 1/5/16, at 9:45 a.m., an interview with certified assistant (CNA 1) was conducted. CNA 1 stated that Resident 5's roommates (Residents 6, 9, and 11) also had rashes and were all itching. CNA 1 stated that Resident 5 had been itching as a result of the rashes for a month. Resident 6 (B bed) had the rash and itching for 3 weeks, Resident 9 (C bed) had the rash and itching for 3 weeks, and Resident 11 (D bed) had been itching as a result of the rash for 3 days. CNA 1 also stated she herself had been itching for 2 weeks and the physician ordered anti itch medication (Hydroxyzine- medication which helps treat the symptoms of allergies and allergic reactions, such as itching, sneezing and sniffling). On 1/5/16, at 9:50 a.m., the administrator and the DON were informed of the findings. The administrator arranged for an immediate Dermatology consultation. At 4 p.m., the DON stated the Dermatologist would see the residents in the evening. On 1/5/16, at 10:20 a.m., during an interview with the Infection Control Coordinator regarding documented evidence of a surveillance log, she stated that there was none. On 1/6/16, at 11 a.m., during an interview with the DON, she stated that there would be another dermatologist coming to the facility to perform skin scraping on all residents. On 1/7/16, at 7 a.m., the DON provided the Dermatologist consult notes dated 1/6/16, indicating Resident 5's scraping result was positive for Norwegian scabies. According to Los Angeles County Department of Public Health, Acute Communicable Disease Control Program, July 2009 - version 3: Human scabies is caused by an infestation of the skin by the human itch mite. Some immunocompromised, elderly, disabled, or debilitated persons are at risk for a severe form of scabies called crusted or Norwegian scabies. Persons with crusted scabies have thick crusts of skin that contain large numbers of scabies mites and eggs and are very contagious to other persons. In addition to spreading scabies through brief skin to skin contact, persons with crusted scabies can transmit scabies indirectly by shedding mites that contaminate items such as their clothing, bedding, and furniture. Persons with crusted scabies should receive quick and aggressive medical treatment for their infestation to prevent outbreaks of scabies. The most common signs and symptoms of scabies are intense itching (pruritus), especially at night, and a pimple-like (papular) itchy rash. During an interview with the dermatologist on 1/7/16 at 2:30 p.m., he stated that Resident 5's infection was positive for Norwegian scabies. The dermatologist stated that the condition had probably existed for a year or so and that this type of infection occurs in debilitated patients who were not being taken care of. The dermatologist also stated that the licensed nurses should have identified the patient's skin problem sooner and that resident should have received the appropriate treatment and prevent the outbreak. The facility's policy and procedure on Skin Assessment, dated 4/2012, indicated: It is the facility's policy to check and assess resident's skin condition upon admission, once every shift, during shower and upon discharge to determine skin condition and assure that the appropriate treatment is implemented. The undated policy and procedure titled "Isolation Measures" indicated: Isolation procedures are designed to help prevent the spread of microorganisms among residents, visitors and personnel. Since the infecting agent (source) and the host factors are more difficult to control, the interruption in the spread of infection is directed at transmission and thus the utilization of special isolation measures. The facility's undated policy and procedure titled "Isolation Measures", indicated it is the responsibility of the Infection Control Coordinator or her designee to notify the attending physician for an order to isolate a resident when there is a suspected infectious process occurring. Isolation precaution should be initiated as a precautionary measure by the Nursing Department until the laboratory results are received. Isolation is to be carried out in accordance with an infection control plan consistent with the health department and Centers for Disease Control. b. Resident 6 was admitted to the facility on 6/24/15, with diagnoses that included diabetes mellitus (high sugar level in the blood), hypertension (high blood pressure) and encephalopathy (disease that affects the function or structure of your brain). The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 10/7/15, indicated that the resident was able to complete the brief mental status interview, understands others, able to make herself understood, and required extensive assistance with bed mobility, transfer, walking in room, dressing, toilet use, hygiene, and bathing. Section M 1040 (D) under Skin condition did not identify skin rashes as evident. During observations with LVN 4 on 1/5/16, at 9:30 a.m., Resident 6 was in bed, awake and lying sideways. During an interview, Resident 6 stated that she was itching on her body. The resident had scattered, multiple, raised reddened papules and red pin point marks on both arms, abdomen, back, and lower legs with itching to both arms, wrists, thighs and legs, chest and back areas. According to LVN 4, the resident was also receiving Triamcinolone (treat a variety of skin condition) 0.1% cream for the rash since 11/18/15. A review of the clinical records indicated a physician's order dated 12/30/15, "cleanse rash on upper back, right side of body with soap and water, pat dry, apply Triamcinolone 0.1% cream and leave open to air two times for 14 days, then re-evaluate.? A review of the nurses notes dated 11/18/15 indicated, Resident 6 had "dermal rash with red color on upper back and right side of the body." The note stated that the physician was made aware and a new order was received as follows: "cleanse dermal rash with soap and water to upper back and right side of body, pat dry and apply triamcinolone 1% cream two times a day for 14 days, then re-evaluate." On 11/27/15, the staff received a physician's telephone order that stated, "discontinue order treatment to skin rash on right and left extremities, resolved. May apply Hydrocortisone 1 % to right and left lower arm for itching tow times a day for 2 weeks as needed (PRN)." On 12/2/15, another physician's order was received to apply triamcinolone to back and right side of the body. There was no documented evidence of a continuing assessment of the skin condition. On 1/5/16, at 1 p.m., during an interview with CNA 1, she stated that Resident 6 had the rash and itching for about three weeks. During an interview with the DON and LVN 4 on 1/5/16, at 9:40 a.m. they both stated that scabies was not ruled out for Resident 6. LVN 4 stated that the physician had not seen and assessed the resident. He added that the CNAs would report to him about their findings, he would do his assessment and call the physician for orders. LVN 4 stated he did not know how that it could be scabies. The DON stated that they do not track or do surveillance of skin rashes and/or infections. According to Davis Drug Guide for Nurses, Ninth Edition, during triamcinolone cream treatment the nurse should assess affected skin before and daily during therapy. Note the degree of inflammation and pruritus. Notify the physician or other health care professional if symptoms of infection (increased pain, erythema, purulent exudate) develop. c. Resident 9 was admitted to the facility on 9/7/15, with diagnoses that included dysphagia (difficulty in swallowing), gastrostomy tube (G tube- an opening into the stomach), Alzheimer's disease (a neurological disorder in which the death of brain cells causes memory loss and cognitive decline) and hepatic encephalopathy (the loss of brain function that occurs when the liver is unable to remove toxins from the blood). The latest Minimum Data Set (MDS), dated 10/14/15, indicated the resident's cognitive skills for daily decision making were severely impaired, and was totally dependent on staff for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. An interview was conducted with CNA 2 on 1/5/15, at 9:45 a.m., she stated she had observed the rash for about 2 weeks. She also stated that she had informed the treatment nurse about it. During a care observation with CNA 2, revealed Resident 9 with scattered, raised papules to her arms, wrist, upper back, left knee and left foot. CNA 2 stated the resident cries whenever she tried to touch her. During a general observation with LVN 4 on 1/5/16, at 9:50 a.m., Resident 9 was lying in bed. Resident 9 was not inter-viewable. According to LVN 4, the resident was not able to state what she wanted. During an interview with LVN 4, he stated the resident was receiving treatment for a skin tear on the right arm but not on skin rash. LVN 4 stated he was not aware of any her skin rash. On 1/5/16, at 9:55, the DON went to the resident's room to check on the rashes. During an interview the DON stated she was not aware of Resident 9's rashes. During a record review with the DON and LVN 4 on 1/5/16, at 10:00 a.m., LVN 4 was unable to find any documented evidence that Resident 9 was assessed with skin rash. On 1/5/16, at 10:30 a.m., during an interview, CNA 1 stated she developed a rash for two weeks. It was observed a pin point red rash on CNA's both arms, upper body and back and legs. CNA 1 stated that the itching was more intense during the night. CNA 1 stated that she informed LVN 4 about her rash but she was informed that it was just an allergy. CNA 1 stated that she went to her own physician and was told that it was an allergy and was prescribed hydroxyzine (used to treat allergies.) During an interview with the DON on 1/6/16, at 11 a.m., she stated that she was not aware of any staff having any skin rashes. On 1/6/16, at 2 p.m., the facility's consultant and treatment nurse were observed performing skin scraping to all four residents that were found to have skin rashes. According to the DON, they obtained physician's orders from the medical director to perform skin scraping for scabies on all residents with rashes. The DON also stated that a dermatologist was scheduled to come to the facility in the afternoon. Isolation precaution was still not implemented. On 1/7/16, at 7:30 a.m., during an interview with the DON she stated the dermatologist performed skin scraping on all residents and found only one resident (Resident 5) positive for Norwegian scabies. d. A review of the Admission Record of Resident 11 indicated the resident was admitted to the facility on June 14, 2014, with diagnoses that included paralysis agitans (progressive disorder of the nervous system that affects movement), hypertension (high blood pressure), diabetes mellitus (high blood sugar), and rhabdomyolosis (a condition in which skeletal muscle is broken down, releasing muscle enzymes and electrolytes from inside the muscle cells). The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated December 27, 2015, indicated the resident was able to complete the mental status interview, understands others and able to make self-understood, and required extensive to total assistance with activities of daily living. During an interview on January 5, 2016, at 10 a.m., Certified Nursing Assistant (CNA) 1 stated that Residents 5, 6, 9 and 11 had a generalized body rash. CNA 1 stated Resident 11 had the body rash for about three days. During an observation on January 5, 2016, at 10:30 a.m., Resident 11 was observed sitting in a wheelchair in the activity room. CNA 1 brought the resident back to her room for a skin assessment. During the skin assessment, Resident 11 was observed with reddened papules (small solid rounded bumps rising from the skin that are each usually less than 1 in diameter) on bilateral hands, wrists, fingers, and ankles. A review of a nurse's note dated January 5, 2016, at 11 a.m., indicated the resident's physician was notified of the rash and new orders for a dermatology consult, skin scraping and contact isolation precaution were received. A review of a physician's order dated January 5, 2016, at 6:10 p.m., indicated the following orders for a diagnosis of dermatitis (inflammation of the skin) unspecified: a. Zyrtec (for allergy)10 milligrams (mg) every morning for four weeks. b. Benadryl (for allergy, cold remedies) 25 mg every night at bedtime for four weeks. c. Clobetasol 0.05% cream to be applied to rash twice a day for four weeks. d. Hibiclens 4% wash to be used all over body once a day for four weeks e. Permethrin 5% to be applied from neck down to toes and left for 12 hours then rinse. Repeat above once a week for four weeks. f. Ivermectin (anti-parasitic) 9 mg once a week for four weeks. During an interview on January 6, 2016, at 8:50 a.m., Resident 11 stated she has had the rashes on her arms for about a month and complained of feeling itchy. The resident stated the staff applied cream on her body last night and gave her medications that made her feel better. During an interview on January 6, 2016, at 8:55 a.m., Licensed Vocational Nurse (LVN) 4 stated that the resident's rashes were first assessed and treated on January 2, 2016. However, a review of the clinical record with LVN 4 did not contain documentation that the resident's skin rashes were assessed and treated until January 5, 2016, after the surveyor questioned it. e. A review of the Admission Record of Resident 12 indicated the resident was originally admitted on December 6, 2014, and was readmitted on January 10, 2015, with diagnoses that included chronic kidney disease, diabetes mellitus, and Parkinson's disease (a degenerative disorder of the central nervous system that belongs to a group of conditions called movement disorders). The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated December 16, 2015, indicated the resident was able complete the brief mental status interview, understands others and able to make self-understood, and required extensive to total assistance with activities of daily living. During an interview on January 6, 2016, at 8:45 a.m., Certified Nursing Assistant (CNA) 2 stated that Resident 12 has a rash and has been scratching for about two weeks. CNA 2 stated she reported this to the charge nurse. On January 6, 2016, at 9:15 a.m., an assessment of the resident's skin was done with Licensed Vocational Nurse (LVN) 4. During the skin assessment, Resident 12 was observed with scattered rash to bilateral upper arms and right flank area and some scratch marks. During an interview on January 6, 2016, at 9:16 a.m. LVN 4 stated he was not aware of the resident's rashes and did not see the rashes yesterday when they conducted a skin sweep of all residents in the facility. LVN 4 stated she would notify the physician and obtain treatment. The facility failed to treat, detect and implement transmission-based precautions in addition to standard precautions, for Resident 5 confirmed positive for scabies, failed to prevent, control cross-contamination and assess skin rashes for Resident 5's roommates , Residents 6, 9, and 11, and for CNA 5 who provided care to these residents. The above violation had a direct relationship to the health, safety or security of the residents. |
| 950000104 |
ROYAL GARDENS HEALTHCARE |
950012814 |
A |
14-Dec-16 |
NEJT11 |
9712 |
CFR 483.25 (c) F314 Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility failed to ensure Resident 5, who was admitted to the facility with no pressure sores and was assessed as high risk to develop pressure sores, was provided necessary treatment and services for prevention of and to promote healing of pressure sores by failing to: 1. Provide turning and repositioning every 2 hours as needed and as indicated in the plan of care to prevent a pressure sore from developing. 2. Monitor for new skin breakdowns and redness, (Stage I or II pressure sores) 3. Report to the physician when a Stage I/II pressure sore developed and obtain treatment orders so as to prevent the resident's pressure sore progression. These deficient practices resulted in Resident 5 developing an avoidable Stage III pressure sore. During the recertification survey initial tour of the facility on June 4, 2015 at 5:45 p.m., Resident 5 was observed lying flat in his bed. During observations on June 5, 2015 at 4:35 p.m., June 6, 2015 at 7:30 a.m., 9 a.m. and 11 a.m., 1 p.m. and 3 p.m., and on June 7, 2015 at 7:30 a.m., 9:30 a.m. and 11:30 a.m., the resident was observed lying flat on his back. During an interview with Resident 5 and his family member on June 7, 2015, at 12:15 p.m. Resident 5 stated staff did not turn and reposition him every 2 hours. Family Member 1 stated that on the previous Thursday (June 4, 2015) at lunchtime, she turned on the call light to get help to reposition Resident 5 in his bed. She stated after 20 minutes she walked out into the hallway to look for someone to help her. She stated the person in charge told her that her nurse was busy with another resident and would help her as soon as she was free. She did not remember who it was. At that time, Family Member 1 stated Resident 5 had a sore on his back. On June 7, 2015, at 12:30 p.m., during an observation with LVN 1, she stated Resident 5 had a Stage III pressure sore that was not identified previously. On June 7, 2015, at 12:35 p.m., during an interview with LVN 1, who was assigned to Resident 5, she stated she had not yet assessed Resident 5 during her shift. At the same time, CNA 1 who was present at the resident's bedside stated he had not noticed any skin breakdown on the resident's back. According to the Nursing Care Ready Reference: Resident Assessment Protocols, Page 61,?Rresidents who have an existing pressure sore should have all pressure eliminated to the sore area, pressure for even a few minutes is too long.? Review of the admission information sheet indicated Resident 5 was re-admitted to the skilled nursing facility (SNF) on April 8, 2015 with diagnoses that included urinary tract infection, quadriplegia (paralysis of all four limbs or the entire body below the neck), and diabetes (a group of conditions that affect the blood sugar levels). Diabetes is associated with prolonged, impaired wound healing. Risk factors emerging most frequently as independent predictors of pressure ulcer development included three primary domains of mobility/activity, perfusion (including diabetes) and skin/pressure ulcer status, Internet PubMed, US National Library of Medicine National Institutes of Health . The Minimum Data Set (MDS, an assessment and screening tool) dated April 15, 2015 indicated Resident 5's cognitive skills for daily decision-making were fully intact, he had impaired range of motion to all extremities, and was totally dependent on staff assistance for all activities of daily living. The resident had an indwelling urinary drainage tube and had no pressure sores /skin problems. The Nursing Admission Assessment dated April 8, 2015 indicated Resident 5 had an old scar in the area near his tailbone. According to the Centers for Medicare and Medicaid State Operation Manual for Pressure Sores 483.25 ( c ), tissue closest to the bone may be the first to undergo necrosis (the death of living cells or tissues), including the sacrum (tailbone). The resident's current skin status was described as dry and warm, no redness or edema noted. A review of the physician's admitting orders dated April 8, 2015 indicated an alternating pressure mattress for skin management, skin breakdown prevention, and pressure sore prevention. There was no documented evidence for May or June 2015, of any current skin treatments being provided, for the prevention of or to promote healing of pressure sores. Review of Resident 5 ' s care plan titled "Risk For Skin Breakdown Related to Immobility and Incontinence of Bowel and Bladder" initiated April 8, 2015, included the interventions of turning and repositioning at least every 2 hours and as needed, monitoring and reporting new skin breaks and redness, and provide good skin care daily and after each incontinence. A care plan titled "At Risk For Discomfort and Pain" initiated April 8, 2015 included interventions to monitor for areas of redness, swelling, pain, inflammation, open areas, change in functioning, and to notify the physician. The care plan was not updated to address Resident 5's Stage III pressure sore. Review of Licensed Personnel Progress Notes from April 28, 2015 to June 7, 2015 indicated no documentation of skin problems for Resident 5. Review of a Braden Scale for Predicting Pressure Sore Risk assessment dated April 8, 2015, indicated a total score of 13, which indicated Resident 5 was a high risk for development of pressure sores. Review of certified nurse aide (CNA) care record forms of Resident 5's activities of daily living from June 1 to June 6, 2015, indicated only the level of assistance the resident required, but did not track how often or at what times Resident 5 was turned, toileted, or cleaned. This was verified in an interview with the Director of Nursing on June 10, 2015 at 10 a.m. Review of Daily Body Check Reports completed by the assigned CNA's including CNA 1, reviewed by the assigned licensed nurse, including LVN 1, and the director of nurses (DON), dated May 29, 2015, to June 6, 2015, all indicated Resident 5's skin was "OK". During an interview with the DON on June 7, 2015 at 4 p.m., she stated she had signed off on the Daily Body Check Reports, but she was not aware Resident 5 had a pressure sore. There was no documented evidence in the clinical record that the facility provided turning and repositioning every 2 hours as indicated in the plan of care, to prevent Resident 5 from developing a Stage III pressure sore. There was no documented evidence in the clinical record that the facility monitored Resident 5 for and reported new skin breakdowns and redness, (Stage I or II pressure sore) and obtained treatment orders, until Resident 5's pressure sore progressed to a Stage III. Once a pressure sore has developed, interventions should be initiated based on the characteristics of the sore e.g., stage, size, location, amount of exudate, type of wound, presence of infection or pain and the resident's general status, Medical-Surgical Nursing, Lewis, Dirksen, Heitkemper, Bucher, Ninth Edition, page 186. It was not until June 7, 2015, at 2:05 pm, after the survey team brought to the facility?s attention, that the facility staff notified the physician of Resident 5?s Stage III pressure sore that measured 3 centimeters (cm) X 1 cm on the tailbone area. The physician ordered the following treatment: Cleanse open sore on the coccyx (tailbone) area with normal saline (salt water), pat dry, apply calcium alginate dressing then cover with duoderm and change every seven days and when needed, for dislodged or soiled dressing. The facility's policy and procedure titled "Daily Body Check Report" undated indicated it is the facility policy to check the resident's body daily to detect any skin problem. The CNA is responsible to indicate all problems found on the patient and document on the report. The LVN is responsible to conduct complete body check on all problem areas noted, report new findings to physician, and document changes in patient's chart. The DON is responsible to review findings and ensure that appropriate action is taken. The facility's policy and procedure titled "Management of at Risk Patients" undated, indicated for patients at risk for skin impairment: inspect skin every week, reposition every 2 hours. The facility failed to ensure Resident 5, who was admitted to the facility with no pressure sores and was assessed as high risk to develop pressure sores, was provided necessary treatment and services for prevention of and to promote healing of pressure sores by failing to: 1. Provide turning and repositioning every 2 hours as needed and as indicated in the plan of care to prevent a pressure sore from developing. 2. Monitor for new skin breakdowns and redness, (Stage I or II pressure sores) 3. Report to the physician when a Stage I/II pressure sore developed and obtain treatment orders so as to prevent the resident's pressure sore progression. These deficient practices resulted in Resident 5 developing an avoidable Stage III pressure sore. The violation presented either an imminent danger that death or serious harm would result, or a substantial probability that death or serious harm would result. |
| 970000165 |
Rose Garden Healthcare Center |
950012941 |
A |
3-Feb-17 |
4T3O11 |
10849 |
483.13 (b) Abuse
The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.
F 225 483.13 (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).
F 323 483.25 (h) Accidents
The facility must ensure that-
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
On 8/25/16 at 11:05 am, an unannounced visit was made to the facility to investigate an entity reported incident.
Based on interview and record review, the facility failed to ensure:
1. Resident 1 was free from physical abuse.
2. Resident 1?s abuse was reported to the facility?s administrator and other officials in accordance with State law including the State survey and certification agency.
3. Resident 1 did not have a potentially hazardous item (knife) in his possession.
A review of the clinical record indicated Resident 1 was admitted to the facility on XXXXXXX16. Resident 1's diagnoses included cellulitis (bacterial infection involving the inner layers of the skin) of the left arm, atherosclerotic heart disease (general term for the progressive narrowing and hardening of coronary arteries), and a right below the knee amputation.
A review of the Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 7/3/16 indicated Resident 1 was cognitively intact. Resident 1 required limited assistance with one person assistance in performing his activities of daily living.
On 8/25/16 at 11:40 am, an interview was conducted with the facility social service designee (SSD) about the7/30/16 alleged abuse incident, who stated Resident 1 told her he was talking with certified nurse assistant (CNA) 2 while in his wheelchair in his room. CNA 1 came inside his room and got something from his bedside cabinet. CNA 1 then placed his arm around Resident 1's neck. Resident 1 felt something sharp against his neck. Resident 1 thought it was CNA 1's fingernail but when Resident 1 touched it he felt that it was the blade of a knife. Resident 1 told the SSD at first he thought it was a joke but later on realized CNA 1 was serious and it was not a joke. The SSD stated Resident 1's knife looked like a kitchen knife with a blue handle which had an approximately four inch blade.
On 8/25/16 at 2:15 pm an interview was conducted with CNA 2 about the CNA 2 stated she was talking with Resident 1 when the incident happened. CNA 2 stated CNA 1 entered the room and called Resident 1 a "cabron (Spanish for as_ _ole)." CNA 1 took something out of Resident 1's bedside cabinet and then placed his left arm around the resident's neck and in his other hand he had a knife. CNA 1 pressed the knife onto Resident 1's neck. Resident 1 was not moving and said to CNA 1 "Are you trying to kill me?" Resident 1 told CNA 2 to take a picture of the scene "so you can see him killing me." CNA 2 stated she did not take a picture of the incident. CNA 2 stated she was shocked to see what CNA 1 did. CNA 2 stated CNA 1 did not say anything and removed his arm from around the resident's neck and placed the knife back on the bedside cabinet and left the room. CNA 2 stated she asked Resident 1 how he felt about the incident. Resident 1 told CNA 2 to not report anything to the facility because CNA 1 might have just been playing. CNA 2 stated she should have reported the incident even if the resident told her not to report it. CNA 2 stated she should have explained to the resident the need to report the incident so that an investigation will be done. CNA 2 stated per the facility policy and from the in-services she learned, she had the obligation to report any abuse incident. CNA 2 stated she should have reported it right away to the charge nurse or administrator.
On 8/25/16 at 2:35 pm an interview was conducted with Resident 1. Resident 1 stated he was sitting on his wheelchair in his room on 7/30/16 and he was talking with CNA 2. CNA 1 came in and tried to "squeeze my neck with his arm." Resident 1 stated he thought CNA 1 was just playing around with him. Resident 1 stated "CNA 1 knows me; I'm like a father to him. I have a knife and he knows I have one and where I placed it. That day, I don't know what came into his mind and why he did that to me." Resident 1 stated, CNA 1 went inside his room and got the knife from his bedside cabinet. CNA 1 put his left arm around his neck and said "I am going to kill you." while pressing an object onto the left side of his neck. Resident 1 thought it was CNA 1's fingernails, but he felt that it was a sharp object, sharper than a fingernail. Resident 1 stated he told CNA 1 "if you are going to kill me, then kill me now." Resident 1 verbalized he got scared and feared for his life. He felt that CNA 1 was going to kill him. Resident 1 stated CNA 1 let go of him, returned the knife without saying anything and walked out the room. Resident 1 claimed the knife touched the left side of his neck but did not cut him. Resident 1 claimed he was thinking about the incident for several days and had a poor appetite after the incident. Resident 1 stated the facility dietitian recognized that his appetite declined. Resident 1 also stated for 3-4 days he could not sleep well thinking about the incident. Resident 1 further stated he had texted CNA 1 that night and asked him ?Why did you do that? You scared me and I was afraid of what you did. CNA 1 responded, ?I was playing and asked for forgiveness.? Resident 1 stated that his grandkids saw the text and told his son. His son asked him about the knife and became upset and reported it to the administrator.
On 8/26/16 at 2:15 pm, an interview was conducted with facility dietary supervisor who stated Resident 1 told her he was not eating well for a few days after the incident. The dietary supervisor stated she could not remember the exact date when the resident told her he wasn't eating well but it was after the incident with CNA 1.
On 9/20/16 at 3:50 pm, an interview was conducted with CNA 1 via phone through a Spanish speaking surveyor. CNA 1 stated Resident 1 had a knife and they were both playing with the knife. CNA 1 stated Resident 1 was his friend and they play around often in the facility. CNA 1 denied placing the knife on the resident's neck. CNA 1 denied that he wanted to kill Resident 1.
On 9/23/16 at 1:45 pm an interview with the facility's MDS coordinator was conducted. The MDS coordinator stated Resident 1 was alert, coherent and cognitively intact and he had no history of making false accusations about staff or residents.
On 9/23/16 at 2:00 pm, an interview was conducted with the facility's director of nursing (DON). The DON stated the facility staff had been educated to report all allegations of abuse. DON stated CNA 2 did not report because she thought Resident 1 and CNA 1 were playing and she was told by the resident not to report. However, the DON also emphasized that all allegations of abuse should be reported and investigated.
A review of the facilities ?incident report 8/11/16 UPDATE?, dated 8/12/16, indicated: ?On August 10th, Resident 1?s son came to visit the facility around lunch time when he heard of the July 30th alleged incident resulting in his request for an investigation.?
The facility staff failed to report the incident to the administrator immediately after it had occurred and the facility did not report the incident to the district office until 11 days after it occurred when Resident 1's son reported the incident.
On 9/23/16 at 2:00 p.m., an interview was conducted with the facility DON. The DON stated residents are not allowed to have knives in their rooms per facility policy. The DON stated the staff conducts room checks every week to make sure no contraband such as knives and sharp objects are in the residents? rooms.
The facility failed to ensure all residents in the facility did not have sharp objects.ÿ Resident 1 had a knife which he used to cut and slice his food. The facility staff was aware he had a knife and did not confiscate it and did not find the knife during the weekly contraband checks.
A review of the facility's undated policy and procedure titled Abuse indicated residents will not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteer staff, family members, friends or other individuals. Physical abuse includes but not limited to hitting, slapping, pinching, kicking and so on. Physical abuse also includes controlling behavior through corporal punishment of a resident. Mental abuse includes but not limited to humiliation, harassment and threats of punishment or deprivation of a resident. It is the policy of the facility to report and investigate all alleged incidents of resident abuse, mistreatment, neglect, involuntary seclusion and misappropriation of property. If the suspected abuse results in serious bodily injury, the facility must report the incident immediately and no later than two hours by telephone to local law enforcement and send a written report within two hours to the local law enforcement agency, the licensing and certification program and the ombudsman. If the suspected abuse does not result in serious bodily injury, the mandate reporter must report the incident by telephone within 24 hours to local enforcement and provide a written report to the local ombudsman, the licensing and certification program and the law enforcement agency within 24 hours.
A review of the facility's undated policy and procedure titled Keeping Sharp Objects indicated residents are not allowed to have sharp objects in their possession to ensure the safety and security of residents, staff and visitors.
The facility failed to ensure:
1. Resident 1 was free from physical abuse.
2. Resident 1?s abuse was reported to the facility?s administrator and other officials in accordance with State law including the State survey and certification agency.
3. Resident 1 did not have a potentially hazardous item (knife) in his possession.
The above violations presented either jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result or a substantial probability harm would result or substantial probability that death or serious physical harm would result. |
| 970000165 |
Rose Garden Healthcare Center |
950013018 |
A |
7-Mar-17 |
QXKN11 |
13712 |
F314-483.25(c) Pressure Sores
Based on the comprehensive Assessment of a resident, the facility must ensure that?
(1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual?s clinical condition demonstrates that they were unavoidable.
On 1/26/17, at 1:30 p.m. the facility?s annual recertification survey was initiated. One of the care issues selected to be investigated during the survey was pressure sores. The facility indicated Resident A had a pressure sore and was selected as a sample resident for the survey.
Based on observation, interview, and record review, the facility failed to ensure Resident A, who was admitted to the facility without a pressure sore (Any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s)) did not develop a pressure sore by failing to:
1. Obtain a physician's order for the use and care of Resident A's right leg immobilizer (A semi-rigid device with straps above and below the knee, used to help prevent unwanted movement that could re-injure the leg or cause harm to the healing area. The area where the straps wrap around the leg to secure the immobilizer to the leg exerts pressure to the leg areas under the straps).
2. Assess and monitor Resident A's skin integrity while using the right leg immobilizer.
These violations resulted in Resident 15 developing the following:
1. Stage I pressure ulcer (intact skin with non-blanchable (does not lose color when you press your finger on it and then remove your finger) redness) of the right knee measuring: 4.0 cm (centimeters) (unit of measurement) in length by 3.0 cm in width.
2. Unstageable pressure ulcer (pressure ulcer with full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green or brown] and/or eschar [tan, brown or black] in the wound bed) pressure injury in the right knee lateral site measuring: 5.0 cm in length by 2.5 cm in width.
3. Suspected deep tissue injury (DTI, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) on the right lateral lower leg measuring: 7.0 cm in length by 4.0 cm in width.
A review of Resident A's Admission Face Sheet indicated the resident was originally admitted on XXXXXXX16 and readmitted to the facility on XXXXXXX 16. Resident A's diagnoses included right femur fracture (break, crack, or crush injury of the thigh bone), muscle weakness, hemiplegia (loss of muscle function), and right hemiparesis (weakness of the entire left or right side of the body).
A review of the Minimum Data Set ([MDS] assessment and care screening tool), dated 11/17/16, indicated Resident A was severely impaired with cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 (a score of 0-7 indicate severe impairment). Resident A required extensive assistance with bed mobility and dressing. Resident A was totally dependent on the staff for transfer, locomotion, toilet use, hygiene, and bathing. Resident A was assessed to have no pressure sores. Resident A was assessed to be at risk to develop pressure sores.
A review of Resident A's Braden Scale (tool to predict pressure sore risk), dated 11/28/16 indicated a score of 12 (score of 12 or less represents high risk). Further review of the form indicated risk factors included limited sensory perception, activity, and mobility.
A review of Resident A's Wound/Skin Record dated 1/9/17 indicated the following:
1. Stage I pressure sore (intact skin with non-blanchable redness over a bony prominence) of the right knee measuring: 4.0 centimeters (cm) in length by 3.0 cm in width.
2. Unstageable pressure sore (full-thickness tissue loss in which the base of the sore is covered by slough/eschar (dead tissue)) to the right knee lateral site measuring: 5.0 cm in length by 2.5 cm in width.
3. Suspected deep tissue injury (characterized by a purple or maroon localized area of discolored skin or a blood-filled blister due to damage of underlying soft tissue from pressure) on the right lateral lower leg measuring: 7.0 cm in length by 4.0 cm in width.
A review of Resident A's physician's order, dated 1/9/17 indicated the following:
1. Cleanse right knee non-blanchable redness with normal saline. Pat dry and apply Hydrogel (water in a gel base, which helps regulate fluid exchange from the wound surface), cover with dry dressing daily for 14 days then reevaluate.
2. Cleanse right lateral knee unstageable pressure injury with normal saline. Pat dry, apply Santyl ointment (removes dead tissues from wound) daily. Cover with dry dressing daily X 14 days then reevaluate.
3. Cleanse right lateral lower leg deep tissue injury with normal saline. Pat dry, apply Santyl ointment daily. Cover with dry dressing daily for 14 days then reevaluate.
During observation and a concurrent interview with Resident A on 1/31/17 at 9:27 a.m., Resident A was observed lying in bed with the head of the bed up. According to Resident A, she used to have the immobilizer on her right leg all the time, but now only uses it when she is up in the wheelchair. Resident A also complained of having more pain since the development of the pressure sores.
During the treatment observation on 1/31/17 at 9:35 a.m., Resident A was observed with an unstageable right lateral knee pressure sore with slough measuring 2.0 cm x 1.5 cm. The pressure sore was located close to the knee cap opening of the immobilizer where the top strap of the immobilizer wraps around the leg. Resident A was also observed with another unstageable right lower leg pressure sore measuring 3 cm x 1.5 cm. The pressure sore was located in the covered area immobilizer close to the lower strap where the rigid bar of the immobilizer sits.
On 1/31/17 at 11:00 a.m., during concurrent record review and interview with LVN 4, he stated, "Resident A was discharged to the hospital after a fall incident resulting in a femur fracture in November 2016. Surgery was not performed, but Resident A was readmitted to the facility with a right leg immobilizer. Resident had another hospitalization and was once again readmitted to the facility on XXXXXXX16 and came with a right leg immobilizer, which was a factor for the development of Resident A's pressure sore." Upon further review of the clinical records, LVN 4 acknowledged that there was no physician order for the use of an immobilizer since readmission on 12/2/16. LVN 4 stated that Resident A should have been evaluated for her right leg's functional mobility and should have had an order for the use of the right knee immobilizer. According to LVN 4, after discovering Resident A's pressure sores on 1/9/17, he notified and obtained an order from the physician to apply the right leg immobilizer only when up in his wheelchair.
Review of Resident A's physician's order dated 1/10/17 indicated an order to remove brace while in bed and apply while in wheelchair.
On 1/31/17 at 11:17 a.m. during interview, LVN 7 stated if a resident was admitted with a brace or an immobilizer, the licensed nurse needs to clarify from the physician when to apply and take off the immobilizer because it places the resident at risk for the development of pressure sores. LVN 4 added that nurses are supposed to assess the resident's skin every shift and document on the nurses' notes.
On 1/31/17 at 11:20 a.m., during interview, Certified Nurse Assistant (CNA 6) stated that Resident A always had the immobilizer on while in bed and on the wheelchair. CNA 6 stated she provided ADL (activities of daily living) care to Resident A, but did not check the resident's right leg because she always had the immobilizer on.
On 2/1/17 at 11:36 a.m., during interview, registered nurse supervisor (RN Supervisor) stated there should be a physician's order for the use of immobilizer, duration of use (i.e. on 4-6 hours per day), and monitoring for skin integrity, pain, and circulation as part of the care and management of residents with an immobilizer. The RN supervisor also stated a care plan should be developed for Residents using an immobilizer.
During observation on 1/31/17 at 12:07 p.m., Resident A was sitting on the wheelchair in the dining room wearing a right knee immobilizer with the right leg resting on top of a pillow and wheelchair leg rest. The right knee immobilizer had a knee cap area opening. There were two rigid bars on the lateral and medial sides of the leg to prevent bending of the knee. There were two straps attached to the immobilizer above the knee and two straps below the knee.
During an interview and concurrent interview on 1/31/17 at 2:42 p.m., with LVN 4, he stated that he left the immobilizer on all the time prior to 1/9/17 because there was no order when to take it off. LVN 4 stated he would only remove the immobilizer strap to check the skin for breakdown and circulation, but did not remove the brace totally. Therefore, he was unable to check the lateral area of Resident A's right leg. LVN 4 stated Resident A's right leg in its entirety should have been assessed daily to prevent pressure sore. A review of Resident A's clinical record indicated there was no documentation that Resident A's right leg was being monitored for skin breakdown when the immobilizer was in place. LVN 4 agreed that there was no documentation that Resident A had been monitored for skin breakdown under the immobilizer.
On 2/1/17 at 11:16 a.m., during concurrent record review and interview with the registered occupational therapist (OTR), he stated aside from Resident A's precautions of no weight bearing on the right lower extremity and no bending, the use of an immobilizer should have been documented in the clinical record, therapy evaluation and ongoing plan. OTR also stated that once a resident is discontinued from physical and occupational therapy, the nursing department should have been instructed on how to apply and remove the immobilizer. OTR emphasized the importance of checking the skin while using the immobilizer to prevent pressure sore. Resident A was discharged from Physical and Occupational therapy services on 1/2/17 with instructions to keep the leg immobilizer on at all times. There was no documented evidence that the nursing staff were given instructions on how to apply and remove the immobilizer to be able to monitor the skin for pressure sore.
A review of Resident A's plan of care titled, "Risk to develop Pressure Sore," dated 12/3/16, indicated a goal for the resident to have no skin breakdown/pressure sore. Staff interventions included to turn and reposition every 2 hours, keep clean and dry at all times, and careful handling during care. A care plan was developed on 1/9/17 addressing Resident A's unstageable right knee lateral pressure injury, DTI of the right lateral lower leg, and right knee non-blanchable redness. Staff interventions in the care plan included treatment as ordered. The care plan did not address the care and management of the right leg immobilizer to prevent further deterioration of pressure sores.
A review of the facility's undated policy titled, "Physician's Order," indicated that medications and treatments may not be administered to the resident without written approval from the attending physician.
A review of the facility's policy and procedure titled, "Pressure Sores/Skin Breakdown," dated 3/2014 indicated that the nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores. It also stipulated that the physician will help the staff review and modify the care plans as appropriate.
The facility failed to:
1. Obtain a physician's order for the use and care of Resident A's right leg immobilizer (A semi-rigid device with straps above and below the knee, used to help prevent unwanted movement that could re-injure the leg or cause harm to the healing area. The area where the straps wrap around the leg to secure the immobilizer to the leg exerts pressure to the leg areas under the straps).
2. Assess and monitor Resident A's skin integrity while using the right leg immobilizer.
These violations resulted in Resident 15 developing the following:
1. Stage I pressure ulcer (intact skin with non-blanchable (does not lose color when you press your finger on it and then remove your finger) redness) of the right knee measuring: 4.0 cm (centimeters) (unit of measurement) in length by 3.0 cm in width.
2. Unstageable pressure ulcer (pressure ulcer with full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green or brown] and/or eschar [tan, brown or black] in the wound bed) pressure injury in the right knee lateral site measuring: 5.0 cm in length by 2.5 cm in width.
3. Suspected deep tissue injury (DTI, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) on the right lateral lower leg measuring: 7.0 cm in length by 4.0 cm in width.
These violations jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 970000165 |
Rose Garden Healthcare Center |
950013183 |
A |
4-May-17 |
FYED11 |
6144 |
F- 323
?483.25(d) (1) (2) Accidents.
The facility must ensure that:
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
On 12/9/2016 at 10:00 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding accidents.
Based on interview and record review, the facility failed to: Ensure Resident 1 received adequate supervision and assistance when repositioning the resident.
This deficient practice resulted in Resident 1 falling out of bed and sustained a fracture of the right distal femur (broken bone on lower end of the thigh bone, near the knee).
A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on XXXXXXX16. Resident 1's diagnoses included: Cerebral infraction (dead brain tissue resulting from blocked blood flow to an area of the brain), hemiplegia (paralysis of one side of the body) of right side, hypertension (chronic abnormally elevated blood pressure), and diabetes mellitus (chronic abnormally elevated blood sugar).
A review of Resident 1's Minimum Data Set (MDS), a comprehensive assessment tool, dated 8/17/16 indicated Resident 1 had a brief interview for mental status (BIMS) score of 6 (0-7 indicates cognitively impaired). Resident 1 was totally dependent with two-person physical assist for bed mobility (how resident moves to and from lying position, turns side to side) and transferring from one surface to another.
A review of Resident 1's corrected MDS dated 11/17/16 indicated Resident 1 had a BIMS score of 6, required extensive assistance with two-person physical assist for bed mobility, required total assistance with two-person assist for transferring.
A review of Resident 1's Fall Risk Assessment, dated 9/6/16 indicated Resident 1 had a fall risk assessment score of 10 (score of 10 and above indicates high risk for fall) (1 point-requires assist with elimination, 1 point-visually impaired, 2 points-balance problems, 1 point-requires a wheelchair, 2 points-takes high blood pressure and diabetic medications, 3 points-history of hemiplegia, cerebrovascular accident (death of brain cells due to blockage of blood flow), and diabetes.
A review of Resident 1's Care Plan, dated 3/16/16 indicated Resident 1 was at risk for fall and injuries secondary to impaired mobility and generalized weakness, required bed side-rails up for mobility. Care plan also indicated to turn and reposition Resident 1 while in bed but did not indicate the number of staff required to perform turning and repositioning.
A review of Resident 1's Nurse's Notes, dated 11/26/16, indicated on 11/24/16, while Certified Nurse Assistant (CNA) 1 was turning Resident 1 onto her left side, Resident 1 slid ?slowly out of bed.? CNA 1 was unable to stop Resident 1 from falling off the bed. Resident 1 landed on both knees onto the floor. Resident 1 noted to have right knee swelling.
During an interview with Resident 1 on 12/8/16 at 11:00 am, Resident 1 stated that CNA 1 turned her to the left side without help from another staff. Resident 1 stated that she usually gets turned by 2 staff and that she does not want CNA 1 to get in trouble. Resident 1 stated that she cannot move her right arm and leg because of stroke (decreased blood flow to a part of the brain). Resident 1 stated that her right leg started to slide down off the bed and she fell with both knees hitting the floor.
During an interview with CNA 1 on 12/8/16 at 12:15 pm, CNA 1 stated that Resident 1 needed two-person assist. CNA 1 stated that she did not call anyone for help because everybody was busy.
During an interview with CNA 2 on 12/8/16 at 1:00 pm, CNA 2 stated that Resident 1 required two-person assist with turning and repositioning. CNA 2 stated that she always asked for help every time she repositioned and turned Resident 1.
During an interview with Registered Nurse (RN) 1 on 12/8/16 at 1:20 pm, RN 1 stated that Resident 1 required two-person assist for all shifts with turning and repositioning. RN 1 also stated that Resident 1 had weakness on the right side of the body due to stroke.
A review Resident 1's "X-Ray of right knee" (photograph to view bone) dated 11/24/16 indicated an acute mildly displaced distal femur supracondylar fracture (broken bone on the lower portion of the thigh bone near the knee).
A review of Resident 1's Physician Telephone Orders, dated 11/24/16 indicated to transfer Resident 1 to the general acute care hospital (GACH) for further evaluation.
A review of Resident 1's GACH History and Physical, dated 11/25/16 indicated: Status post fall with a right distal femur fracture, right leg splinted (a device used to support or immobilize), pain controlled, and waiting for orthopedic (physician that specializes in diseases of the bone) consult.
A review of Resident 1's GACH Orthopedic Consultation Note, dated 11/25/16 indicated a plan of non-weight bearing to the right lower extremity, gentle activity of transfers from bed to bed, recheck to evaluate possible interval displacement (change in alignment of broken bone), if so, surgery would be indicated.
A review of facility's policy and procedure titled "Fall Risk Assessment" dated 11/2007 indicated staff will evaluate functional factors that may increase fall risk which included ambulation, mobility and activities of daily living capabilities; staff will identify and address modifiable fall risk factors to try to minimize the consequences of risk factors that are not modifiable.
Therefore, the facility failed to the facility failed to: Ensure Resident 1 received adequate supervision and assistance when repositioning the resident.
This deficient practice resulted in Resident 1 falling out of bed and sustained a fracture of the right distal femur (broken bone on lower end of the thigh bone, near the knee).
This violation presented a substantial probability that death or serious physical harm would result. |
| 960002060 |
RAYMOND HOUSE |
960009040 |
A |
16-May-12 |
BTZK11 |
17915 |
Title 22 76875. Health Support Services- Nursing Services. (b) The attending physician shall be notified immediately of any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a client.On July 16, 2010 at 6 a.m., an unannounced visit was made to the facility regarding the death of a Client. The Department received a faxed letter from the facility on June 16, 2010 indicating the facility?s nurse arrived at a hospital on June 14, 2010 to visit Client 1 and was informed the Client had expired during surgery.Based on interview and record review, the facility failed to ensure Client 1?s physician was immediately notified of the client?s change in condition by failing to:1. Notify the physician when the Client had decreased appetite as indicated by the client repeating she was not hungry and refusing to eat. 2. Notify the physician when the client exhibited increased weakness, as indicated by the client by not being able to feed herself and not swallowing all of her medication. Review of Client 1?s face sheet revealed the client was admitted to the facility on December 8, 1997 with client diagnoses that included mild mental retardation (developmentally functions at one half to two thirds of chronological age, is slow in all areas, but can acquire practical and vocational skills), hypertension (high blood pressure), and seizure disorder (epilepsy, a brain disorder involving repeated, spontaneous convulsions).An Annual Individual Service Plan (ISP), dated May 4, 2010, indicated the 66 year old client engaged in conversations, had a good attention span, a good long term- memory and a physical therapy objective to stand for two minutes holding on to a secure surface ?3 trials a day?. A quarterly nurse assessment, dated February 28, 2010, indicated the client ate without difficulty 90-100% of her meals. A Nutritional Assessment completed by the registered dietician, dated April 25, 2010, indicated the client ate 80-100% of her meals, fed herself slowly, drank from the cup, used utensils, and was on aspiration precautions (interventions to prevent breathing foreign materials- food, liquids, vomit, or fluids from the mouth into the lungs).On July 16, 2010 at 6:29 a.m.-7:10 a.m. during an interview, Staff A stated when she arrived at work the night of June 3, 2010, she was informed by other staff that the client was very weak, would not watch television, was very quiet and only ate approximately 20-30% of her meal. The client was too weak to hold her cup to drink, therefore, Staff A tried to spoon the client water which dribbled out of the client?s mouth. Prior to Monday, May 31, 2010, the client was able to drink. Staff A further stated, on Thursday, June 3, 2010 the client was not smiling and she was not herself. She informed all of the Friday morning staff and the RN about the client?s behavior. The RN told her to keep watching the client?s behavior. On June 4, 2010, Friday morning, the client would not eat anything that Staff B tried to give her. She had been working with the client for about ten years and knew something was wrong with the client.On July 16, 2010 at 6:45 a.m., during an interview, Staff B stated the client was not feeling well the week of May 31-June 5, 2010, but she did not know the client was that ill. Later at 7:50 a.m., the client had slowed down the week of June 1, 2010 and was not eating. The RN had come to the facility about twice that week and told the staff to make sure the client drank liquids. There was no documented evidence provided by the facility that indicated the physician was notified.On July 16, 2010 at 7:55 a.m., during an interview, Staff C stated the week of May 31-June 5, 2010 the client was not herself. The client was not responding and not eating. The staff had to feed the client hand over hand (holding the back of the client?s hand and guiding her through the motions of the activity to be learned or assisted with) whereas, before that week the client fed herself. The client did not have any energy. The Client did not take one of her medications because she was too weak to swallow.The client?s pill was found on the client?s shirt and placed in the trash. Staff C was not sure if the RN was notified that the client did not take her medication.The client was not joking nor smiling as she had usually done. Further more, for a couple of days during that week, the client went from one person assist to two persons assist, because she was not able to neither move her buttocks nor stand up. The client was no longer able to hold the shower hose during bathing. The RN was called Tuesday (June 1, 2010) and the RN told the staff to make sure the client got plenty of rest and plenty of liquids. The RN told them not to make the client go to her day program.According to Staff C, she stayed at the facility with the client on Wednesday, June 2, 2010 and the client laid down and refused to carry out her objective of listening to music. Also that day the client was given ravioli for lunch, only took 2-3 bites and drank approximately 4 ounces of juice and water. The RN came to the facility that day (the nurses notes indicated the RN was at the facility at 10 a.m.) and remained until two o?clock.A review of the client?s five ISP Objective Data Sheets indicated the client refused to participate in the following daily objectives from June 1 through June 4, 2010: fifteen minutes of passive range of motion, choose her clothing, propel her wheelchair from the front door to the outside fountain, listen to music or nature sounds for thirty minutes, and answer multiple choice questions.A review of the client?s Habilitation flow sheet indicated on June 1, 2010 (Tuesday), the client refused to eat breakfast and dinner and was at the school (day program) for lunchtime (at the day program, the client did not eat her lunch).The flow sheet indicated the client only ate 40-50% (?five spoonfuls? per the RN) of dinner on Wednesday and Thursday. The flow sheet indicated she refused lunch on Wednesday (June 2nd), Friday (June 4th), Saturday (June 5th) and dinner on Friday (June 4th).On July 16, 2010, at 9 a.m., during an interview the RN stated she received a call on June 1, 2010, from the day program nurse who was concerned the client did not eat. The client usually had a good appetite. She informed the facility staff to watch the client and make sure she received plenty of fluids. The RN stated the client was not her usual self. The client?s primary care physician and the nurse practitioner were not notified of the client?s change in condition because she did not think it was warranted. The RN revealed she usually visited the facility twice a week, but because the client was not her usual self, she visited the facility four times that week prior to the client?s hospitalization. Staff did not report anything to her regarding the client on Friday, June 4, 2010, but she was a little concerned about the client?s decrease in appetite. Staff told her Saturday morning the client ?did not want to get up? and when she went to see the client, ?She was not her chipper self?. The client ate a couple of bites of cereal and drank 4 oz. of liquids for breakfast that same morning. The client would only eat what she liked and nothing else was offered if she did not like what was served. She asked the client questions and the client nodded off to sleep during the questioning. The RN said, when the client was admitted to the hospital she did notice the client?s urine was cloudy (indicating possible infection) when the Foley catheter was inserted. The RN stated, ?Just two days of not eating much was not reason to contact the doctor?.A review of the facility?s undated policy and procedure titled, ?Signs of Illness in the Developmentally Disabled Individual?, indicated signs and symptoms that may indicate illness included: change in behavior, increase in anxiety, decrease in alertness, lethargy (appearing tired, no energy), change in appetite, change in bowel or bladder habits, any cough, wheezing or difficulty breathing, or any indication of pain anywhere. According to the policy, the registered nurse (RN) consultant MUST be notified of any suspected signs of illness. Staff was advised to avoid diagnosing and just relate the symptoms that were observed.On July 16, 2010 at 9:32 a.m., during a telephone interview, the qualified mental retardation professional (QMRP) stated it was the nurses responsibility to determine when the physician should be contacted.A review of the day program?s time log/census report dated June 2010 indicated the client was present, June 1, 2010 9:30 a.m. through 1:50 p.m.The log further indicated Wednesday June 2, 2010 through Friday June 4, 2010 the client was absent. A review of nursing narratives written by the RN, submitted to the surveyor July 19, 2010 by the RN indicated on June 1, 2010 the facility RN, received a phone call from the day program nurse informing her the client was not eating well, was looking down and was not herself and stated she was not hungry. The facility RN narratives further indicated she was present in the facility from 11:45 a.m. to 5:45 p.m. and she took the client?s vital signs (time not documented) which were; apical pulse (AP) 87, blood pressure (BP) 134/82, temperature (T) of 98 Fahrenheit and respirations (RR) approximately 11-12 (11 was slightly below normal). The RN narrative further indicated the client had decreased breath sounds (the sounds heard with and without a stethoscope produced by the lungs during breathing) on the right lungs and wheezing (a high pitched whistling sound made when air flows through narrowed airways in the lungs, usually when people breathe out). The RN asked the client what was bothering her and the client informed her she had a headache for which the RN provided her with a Tylenol orally. On the evening of June 1, 2010 the nurse stated she called the facility and was informed by staff the client was complaining of being tired and ate less than normal. The physician was not notified. A review of the nursing narratives written by the RN indicated on June 2, 2010 at 10 a.m. the RN went to the facility to evaluate the client. The client?s vital signs were: 130/84 BP (84 was slightly elevated), 64 pulse, 12 RR. The narrative indicated the client ate a little breakfast.On July 20, 2010 at 3:20 p.m., during a telephone interview, Staff D stated the client was not eating well. Staff D stated, beginning Tuesday, June 1, 2010, the client was only able to slowly eat approximately half her food until Friday, June 4, 2010 when the client could no longer pick up her spoon and did not have the strength to chew her food.Staff D stated she did not inform the nurse of the client?s condition, but Staff B may have informed the nurse of the client?s condition on Saturday (June 5, 2010).On July 22, 2010 at 10:24 a.m., during an interview, the RN stated she did not know the client was not eating and she did not know the client remained home June 2 - June 4, 2010. The RN stated she was the only one who took vital signs because she was not aware the facility staff could take vital signs.A review of the nursing narratives located in the chart dated June 3, 2010, indicated the RN called the house on June 3, 2010 and was informed the client ?just seem down, wasn?t hungry? and the staff informed the RN the client had periods of depression. There was not documented evidence provided by the facility of the client having clinical depression or that the physician was notified of the client?s change in condition. A review of the nursing narratives located in the chart dated June 5, 2010, indicated the RN called the facility and Staff B informed her, the client ?did not eat and was not herself?. The narrative further indicated at 11 a.m., the RN saw the client in bed, appearing lethargic and nodded off to sleep when the RN tried to question her. The narrative indicated the client vital signs were: BP 60/40 sitting and 70/50 lying down, AP 100 thready (weak, lacking fullness) and irregular, RR 12-16. The nursing narrative further indicated the client breath sounds were decreased at the base of the lungs and her pupils reacted slowly to light. The nurse called 911 emergency services. The only nursing narratives that were located in the chart were dated June 3, 2010 through June 5, 2010. There was no documented evidence provided by the facility that the physician was notified. A review of the paramedic run sheet dated 05/06/2010 (the month and date was reversed, correct date 06/05/2010 via telephone interview with EMS) indicated emergency services were dispatched at 2:29 p.m. and arrived at the facility at 2:32 p.m. The paramedic run sheet indicated the client had been lethargic for 3 days, was cold, with a BP of 80/60, pulse of 80, RR 12 and oxygen saturation of 98% on an oxygen mask. According to the paramedic run sheet the client?s 12 lead heart rhythm (EKG) was abnormal and the client was given oxygen and normal saline intravenous fluids (fluid given through the veins).A review of the hospital emergency room records, dated June 5, 2010 indicated at 3:30 pm the client arrived via EMS (emergency medical services) lethargic, unresponsive, grimacing, with a metabolic alkalosis arterial blood gas (blood drawn from an artery that showed the exchange gases in the body were not within normal limits), purulent urine (pus in urine, cloudy white due to white blood cells indicating infection) returned from Foley catheter (a tube inserted into the place urine comes from to the bladder to remove urine). The records further indicated at 4 p.m. the client?s oxygen level decreased and the client was intubated (a tube inserted down the windpipe to maintain open airway support) and placed on a ventilator (a machine that assist a person to inhale oxygen and exhale carbon dioxide from the lungs) at 4:15 p.m.At 10:30 p.m. the client was placed on a dopamine drip (medication used to raise blood pressure) - BP 88/55.The clinical impression was sepsis (severe infection) secondary to urinary tract infection, encephalopathy (disorder of the brain) secondary to infectious illness, respiratory failure (unable to breathe properly), renal failure (kidneys not working properly) and hypercalcemia (elevated levels of calcium in the blood).According to the pulmonary consultation dated June 6, 2010, the client was admitted to the hospital intensive care unit and was treated conservatively during the night and in the morning. The client remained on assist control ventilation (ventilator provided a mechanical breath every time the patient initiated a breath to make the breath effective).According to the operative report dated June 14, 2010, the client expired on June 14, 2010 following bronchospasm (abrupt abnormal constriction of the small muscles inside the lung preventing air passage) post tracheostomy (access placement via an incision into the neck windpipe that allows breath without their nose or mouth) operation.According to the death certificate the 66 year old client?s cause of death was hypoxic encephalopathy, difficult intubation and tracheostomy for chronic renal failure contributed by hypertension and urosepsis (systemic blood infection that develops when a urinary tract infection pathogen enters the bloodstream and disseminates throughout the entire body. A lay term for this critical condition is "blood poisoning"). On July 16, 2010 a review of the facility?s undated one page policy and procedure provided by the RN, titled ?Notification Policy and Procedure? indicated direct staff have the responsibility of immediately (when it happens) notifying the program manager, the RN consultant and the qualified mental retardation professional (QMRP) when a client is ill. However the staff was required to call 911 for emergency situations (uncontrolled bleeding, loss of consciousness or not breathing).On July 22, 2010, a second review of the facility?s undated two page policy and procedure provided by the QMRP and the RN, titled ?Notification Policy and Procedure? indicated a second page belonged to the same policy which indicated, the RN consultant is responsible of notifying the physician of a consumer?s change of condition.On July 29, 2010 at 2:44 p.m., during a telephone interview, the client?s primary care physician stated he would have liked to have seen the client when she began exhibiting a change of condition. The client had a change of condition when she exhibited a change in appetite.The physician stated once the client did not eat three meals it would have been warranted to take the client to the hospital. If the client?s condition had not improved within 24-48 hours the facility should have called the physician or if after hours, the client should have been taken to the emergency room. The facility failed to ensure the Client?s physician was immediately notified of the client?s change in condition by failing to:1. Notify the physician when the Client had decreased appetite, indicated by the client repeating she was not hungry and refusing to eat. 2. Notify the physician when the client exhibited increased weakness, as indicated by the client by not being able to feed herself and not swallowing all of her medication. The facility?s failure to ensure the Client 1?s physician was immediately notified of the client?s change in condition resulted in the client receiving delayed medical assessment and treatment.The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. 1 |
| 960000872 |
ROSE DIVISION |
960009932 |
B |
07-Jun-13 |
8FG111 |
5725 |
WIC 4502 (h) Class B Citation 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 development disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) Right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect.Based on interview and record review, the facility failed to: 1. Ensure the safety for Client 4 by using hot water to groom the client?s hair, which resulted in the client sustaining three blisters, second degree burns (burn through the first layer of skin and the second layer of skin is also burned), to her back. On March 14, 2013 at 6 a.m., an unannounced visit was made to the facility to conduct a recertification survey. According to the Admission Face Sheet, Client 4 was admitted to the facility April 14, 2005, with diagnoses that included Profound Mental Retardation (cognitive ability that is markedly below average-less than one-fifth of chronological age-incapable of self-care). According to the Occupational Therapist?s evaluation, dated June 7, 2012, the client was non-verbal and ambulatory. A review of the change of condition/incident report dated June 5, 2012, indicated Client 4 had blisters on her back from when she had her hair dipped into hot water on June 4, 2012. The client sustained three separate blisters; two top right blisters were 4 centimeters (cm) x 1 cm, and 2 cm x 2 cm, and the blister located in the middle of the back was 3 cm x 3 cm, dark red in color and slightly raised. During an interview with the house manager, on March 18, 2013, at 8:20 a.m., she stated Staff A explained to her that, while braiding add-on extension hair to the client?s hair, the hair was dipped into hot water, and resulted in the blister burns on her back. The house manager stated she gave an in-service to staff as a result. The in- service record, dated June 5, 2012, indicated:? When doing French braids, change your method of dipping braids because it is unsafe for clients. So please, when blow drying or doing anything with the clients? hair when heat is involved, you need to take safety precautions, by making sure the clients are covered well and safety first always.? A review of the Interdisciplinary Progress Note, written by the Registered Nurse Consultant (RNC), dated June 5, 2012 (a.m. shift),indicated the client had dark red, and slightly raised blisters located on her back. The top right blisters were 4 cm x 1cm, and 2 cm x 2 cm, and the blister located in the middle of the back was 3 cm x 3 cm. During an interview with the RNC, on March 18, 2013, at 10 a.m., he reviewed the progress note he wrote on June 5, 2012 and stated he was the licensed vocational nurse for night shift during that time, and he remembered the events of that day. The RNC stated Staff A showered the client in the morning and saw the blisters, after which, he was notified and assessed the client. He stated Staff A completed the incident report immediately after observing the blisters, and that was how he became aware Staff A was the one braiding the client?s hair using hot water. The RNC stated he understood the burns came from the hot water on the hair touching her back. A review of the physician?s order dated June 5, 2012, indicated to apply Silvadene cream (topical medication for the prevention and treatment of wound infection for clients with second- and third-degree burns) to affected areas (blisters) twice daily for 14 days. According to the physician?s note dated June 13, 2012, the client had blisters on her back after having her hair styled. The note further indicated the blisters were resolving, and to continue administering the Silvadene cream. A review of the Interdisciplinary Progress Note dated June 6, 2012, late entry for June 5, 2012, indicated the licensed vocational nurse (LVN 1), notified the registered nurse and physician, and obtained a telephone order for the Silvadene Cream. During an interview with LVN 1, on March 18, 2013 at 10:25 a.m., she reviewed the progress note she wrote on June 6, 2012 and stated she remembered the event. LVN 1 stated the client?s blisters/wounds had drainage during the healing process, and the client?s shirt would stick to her body when she sat down. During an interview with the qualified mental retardation professional (QMRP), on March 18, 2013 at 3:35 p.m., she stated Staff A no longer works at the facility. The QMRP also stated she wrote a note on the incident report that read she will speak with Staff A about braiding the client?s hair using hot water. She explained Staff A covered the client?s back and shoulders with a towel, the hair was dipped into hot water to make it more manageable/remove the stiffness, and during the braiding process the client impulsively removed the towel, and the hair fell on her back area instead of the towel causing the blisters. The QMRP did not indicate water temperatures were checked, only that hot water was needed and the towel was used as a safety measure. Failure to ensure the safety for Client 4 by using hot water while grooming the client?s hair, resulted in three second-degree blister burns, had a direct relationship to the health, safety, and security of the client. |
| 960001603 |
R & D HOME CARE |
960012719 |
B |
3-Nov-16 |
H4KW11 |
2712 |
Title 22 76845 The securing of criminal records shall be accordance with the provisions of Section 1265.5 of the Health and safety Code. 1265.5 (f) (f) Upon the employment of any person specified in subdivisions (a), and prior to any contract with clients or residents, the facility shall submit fingerprint cards to department for the purpose of obtaining a criminal record check. On 8/30/14, a recertification survey was conducted. Based on interview and record review, the facility failed to: 1. Ensure a criminal clearance (pre-employment background check) for two staff members (Staff A and Staff B) were submitted to the Department of Justice (DOJ) prior to providing care for 6 of 6 clients in the facility. This failure had the potential for not ensuring the safety and well-being of 6 clients residing in the facility. On 8/30/2014 at 10:40 A.M., a review of new employee files indicated Staff A was hired as a direct care staff (DCS, non-license care giver) on 5/3/14 and Staff B was hired as a direct care staff on 5/12/14. Further review of the new employee files indicated there was no documented evidence that the facility had submitted fingerprints to the Department of Justice for the purpose of securing criminal record clearance for Staff A and B. On 8/30/14, at 11:00 a.m., Interactive Voice Response Unit (IVRU) was called to check for criminal clearance for Staff A and B. The IVRU indicated Staff A?s and staff B?s fingerprint cards were not found (not submitted). On 8/30/14, at 11:30 a.m., during an interview with the Qualified Intellectual Disabilities Professional (QIDP), he confirmed that Staff A and Staff B did not have a criminal record clearance. The QIDP stated he was not aware of this issue because he was not employed at the facility during the month of May 2014. A review of the Clients? medical records indicated Client 1, 2, 3, 4, 5, and 6 had diagnoses that included intellectual disability (delays in reasoning, learning, problem solving). The clients were dependent on staff for all activity of daily living including walking, transferring, eating and toileting. A review of the facility?s undated policies and procedures titled ?Incidents/Abuse Reporting? and ?Client Abuse? indicated there was no procedure to screen employees for criminal history. The facility failed to ensure fingerprinting clearance for two staff, Staff A and B, who worked in the facility, was completed prior to having contact with the clients. This failure had the potential for not ensuring the safety and well-being of 6 clients residing in the facility. The violation had a direct relationship to the health, safety and security of clients. |
| 960002538 |
RCN PEDIATRIC CARE II |
960012803 |
A |
15-Dec-16 |
1UWS11 |
7542 |
4502(h) Welfare and Institutions Code Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which received public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility's staff failed to protect Client 1 from harm, by failing to follow the facility's policy and procedure on two-person transfer for one client (Client 1). Client 1 weighed more than 50 pounds (lbs.) and according to the facility's policy and procedure; the client needed a two person transfer. Direct Care Staff (DCS 1) transferred Client 1 by himself. When DCS 1 lifted Client 1 up from the shower chair, he heard a cracking sound. DCS 1 stated at the same time, the client grabbed his left leg and cried. This deficient practice resulted in Client 1 sustaining a left femur fracture (fracture of the thighbone, closest to the hip bone) and was hospitalized for six days. During an investigation at the facility on 8/9/16, at 2:30 pm, Client 1 and DCS 1 were not in the facility. A review of Client 1's clinical record indicated the client was admitted to the facility on xxxxxxx with diagnoses that included cerebral palsy (is a disorder that affects muscle tone, movement, and motor skills) and unspecified intellectual disability (limitation in mental functioning). During an interview with the facility's Registered Nurse/Administrator (RN/ADM), on 8/9/16, at 2:40 pm, she stated DCS 1 was fired from his job and Client 1 was transferred to another facility per the client?s parent request. During a telephone interview with DCS 1, on 8/9/16, at 3:45 pm, he stated on 7/27/16, at 6 am, he transferred Client 1 from the shower chair to the client's bed. DCS 1 stated he lifted the client up by putting his left hand behind the client's neck and his right hand behind the client's knees. DCS 1 stated as he lifted Client 1 up from the shower chair, he heard a cracking sound and noticed the client was crying. DCS 1 stated he carried Client 1 to the client's bed. DCS 1 stated when he touched the client's left knee; the client grabbed his left leg and cried more. DCS 1 stated he was supposed to transfer the client with two-person transfer but there were no other staff in the facility at that time. DCS 1 stated morning shift staff (DCS 2) came in at 6:30 am. DCS 1 stated the client weighed less than 60 lbs. and he believed that he was capable of carrying the client by himself A review of the facility's staffing schedule for 7/26/16 to 7/27/16, indicated on 7/27/16, DCS 2 (day shift staff) started her shift at 6:30 am. During an interview with the RN/ADM, on 8/9/16, at 4:00 pm, she stated DCS 1 should have waited for other staff to arrive so he could transfer Client 1 by using the two person transfer technique. The RN/ADM stated according to the facility's policy, staff needed to use a two person transfer technique to transfer clients who weigh more than 50 lbs. A review of the facility's undated policy and procedure titled "Two Person Lift, on an Individual," indicated a two person lift should be used when an individual is greater than 50 pounds (lbs.) One staff member stands behind the individual, the staff may reach in and grasp the individual under his/her arms/around the trunk. The second staff member stands at the legs and reaches under both buttocks/thighs (hands should be higher than the knees). Staff will ensure no upper/lower extremities (arms/legs) are hanging and dangling during transfer. A review of the RN's notes, dated 7/27/16, at 6 am, indicated DCS 1 texted/reported to the RN that while DCS 1 was transferring Client 1 from the shower chair to the wheelchair, DCS 1 heard a popping/crackling sound from the client?s hip/femur. Client 1 was holding on the client?s left lower extremity and moaning as if something was bothering him. The RN instructed DCS 1 to apply an immobilizer to the client?s left lower extremity and gave the client Motrin (pain medication) for pain. The RN called the hospital for an appointment and gave a second dosage of Motrin for pain prior taken the client to the hospital. At 12 pm, the client left the facility for the appointment at the hospital. The client was admitted to a General Acute Care Hospital (GACH) on the same day (7/27/16) for femur fracture. The surgeon (doctor who performs surgery) planned for surgery in the morning of 7/28/16. A review of the GACH's orthopedic surgeon?s surgery note (doctor that specialize in diseases and injuries of the musculoskeletal system), dated 7/27/16, indicated Client 1 was being moved by a care giver this morning when the care giver heard a "crack" in the client's left leg and felt the client's leg give way and deform. Client 1 was assessed to have gross deformity to the left hip and a left femoral shaft (along the thighbone) fracture. The surgeon planned for a bilateral hip hardware removal and open reduction with internal fixation of the left hip. The report indicated Client 1 weighed 26 kilogram, equivalent to 57.33 lbs. A review of Client 1's peri-operative report, dated 7/28/16, indicated the client presented to the emergency room yesterday (7/27/16) after suffering a femur fracture while being transported and transferred by his caregiver. Client 1 sustained a midshaft (in the middle of the thighbone) spiral (bone fracture occurring when a rotating force is applied along the axis of a bone and often occur when the body is in motion while one extremity is planted) femur fracture. The client underwent hardware removal from bilateral femurs and open reduction, intramuscularly nailing of the left femur fracture (ORIF, Open reduction refers to surgery to set bones, as is necessary for some fractures. Internal fixation refers to fixation of screws and/or plates to enable or facilitate healing). The client also required a blood transfusion during the surgery. A review of the hospital?s Discharge/Transfer/Home Care Notes, from 7/27/16 to 8/3/16, indicated the client was hospitalized 6 days, and his post-operative course was complicated by hypotension (low blood pressure) that was attributed to medications. The facility's staff failed to protect Client 1 from harm, by failing to follow the facility's policy and procedure on two-person transfer for one client (Client 1). Client 1 weighed more than 50 pounds (lbs.) and according to the facility's policy and procedure, the client needed a two person transfer. Direct Care Staff (DCS 1) transferred Client 1 by himself. When DCS 1 lifted Client 1 up from the shower chair, he heard a cracking sound. DCS 1 stated at the same time, the client grabbed his left leg and cried. As a result, Client 1 sustaining a right femur fracture and was hospitalized for six days. 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. |
| 960002060 |
RAYMOND HOUSE |
960013257 |
A |
11-Jul-17 |
GB6111 |
8241 |
Title 22: 76872 Developmental Program Services-Staffing
(f)The primary responsibility of direct care staff shall be the care and training of the clients as follows:
(2) Direct care staff shall not be diverted from their primary responsibilities by excessive housekeeping, clerical duties or activities not related to client care when clients are physically present in the facility.
On March 30, 2017 at 5:45 a.m., an investigation of an Entity Reported Incident (ERI) was initiated, regarding Client 1 being left alone March 28, 2017, in the facility on the toilet for 5 hours and 30 minutes.
The facility staff failed to:
1. Ensure Client 1 received proper care and treatment. Client 1 was left alone in the facility while seated on the toilet from 10 am until 3:30 pm, resulting in bruising to her buttocks (and potential pain or tissue breakdown from poor circulation). Client 1 remained seated without staff prompting her to move. According to Staff T, she was responsible to care for Client 1. Staff T assisted the client with morning care then proceeded to do laundry.
2. Follow their policy for care and treatment, toileting and supervision.
During an observation of Client 1, on March 30, 2017 at 6:10 am, there was reddish circular bruising on her buttocks area in the shape of the toilet seat.
During a review of the clinical record for Client 1, on March 30, 2017, the face sheet indicated Client 1 was admitted to the facility XXXXXXX 1999 with diagnoses that included: Downs syndrome (chromosome anomaly), profound intellectual disability (cognitive ability that is markedly below average level, incapable of self-care) and neurogenic bladder (minus nerve control of the bladder resulting in involuntary urination).
The Comprehensive Functional Assessment (CFA) dated October 6, 2015, indicated Client 1 required staff assistance for activities of daily living (ADL).
A review of the Occupational Therapist (OT) (people who are designated to help clients participate in the things they want and need to do through the therapeutic use of everyday activities) evaluation/ assessment dated October 7, 2016, indicated Client 1 is non-verbal, inconsistently followed simple directions, and was ambulatory, but sometimes does not want to walk and needs encouragement. The OT evaluation further indicated Client 1 wore adult diapers, but is able to use the toilet, and needs improvement in all activities of daily living.
A review of the Physical Therapy (PT) (work with patients to help them regain movement) evaluation/assessment dated September 28, 2016, indicated Client 1 requires staff assistance for functional ambulation and will remain sedentary without prompts from staff to move. Client 1 requires balance assistance of staff and prefers hand held assistance and requires person assistance to stand.
A review of the Annual Individual Service Plan, dated October 12, 2016, indicated Client 1 weighs 98 pounds and wears eye glasses for distance. Client 1 who has no safety awareness, no family involvement since placement, she has no comprehension of money and she is unable to make purchases.
During an interview with Staff T, on March 30, 2017 at 6:15 am, she stated on the morning of March 28, 2017, she was assigned to provide care for Client 1. Staff T stated she showered, dressed, and fed Client 1. Staff T stated after providing activities of daily living (ADL), she sat Client 1 on the sofa and proceeded to do the laundry. Staff T stated the bus arrived and she and Staff Q placed all the clients except Client 1 on the bus. Staff T stated she assumed Staff J assisted Client 1 on the bus. Staff T stated she did not put Client 1 on the toilet and Staff J was responsible for cleaning the bathrooms when the clients leave for the day program. Staff T stated she was not scheduled to work that afternoon but after 3:30 pm, she received a phone call from Staff Q who informed her that when she arrived to the facility she found Client 1 seated on the toilet, and alone in the facility. Staff T stated she went to the facility to make sure Client 1 was okay. Staff T stated she observed Client 1 having a large red circular mark on her bottom after Staff Q removed her from the toilet.
Staff T stated she attempted to notify the administrative staff which included the administrator and house leader but she did not speak with anyone regarding Client 1 being found on the toilet and being left alone. Staff T stated the qualified intellectual disabilities professional (QIDP) called her at 9 pm that night, informing her that leaving the client on the toilet and alone was grounds for termination. Staff T stated she took full responsibility for Client 1 being left in the facility because she was assigned to provide care for Client 1 that day.
During an interview with Staff J, on March 30, 2017 at 7:03 am, she stated the morning of March 28, 2017, she did not take care of Client 1. Staff J stated she did not feed, bathe, or toilet her and that she heard Staff T tell Client 1 to go to the restroom. Staff J stated she cleaned and mopped the hallway and cleaned both bathrooms after the clients left, but did not see Client 1 on the toilet. Staff J stated Staff T was responsible for Client 1 that morning and for Client 1 staying on the toilet from 10:00 am until 3:30 pm (5 hours and thirty minutes).
During an interview with Staff Q, on March 30, 2017 at 11:45 am, she stated she and Staff T assisted 5 clients on the bus and after the 5 clients were boarded on the bus, she clocked out for the day. Staff Q stated when she arrived, at 3:15 pm, she waited around in the living room area, but at 3:30 pm, she went into the bathroom and was frightened to see Client 1 on the toilet. Staff Q stated she called Staff T and informed her that someone left Client 1 on the toilet alone in the facility. Staff Q stated she did nothing else; she did not call the administrator or the HL. Staff Q reiterated, "I did not do anything."
During an interview with the house leader (HL), on March 30, 2017 at 9:10 am, she stated Staff Q, Staff J, and Staff T did not notify administration that Client 1 had been left at the facility alone on the toilet. The HL stated she was concerned that staff did not take ownership for who placed the client on the toilet.
During an interview with the QIDP, on March 30, 2017 at 1:45 pm, she stated she was informed of the incident regarding Client 1 being left alone in the facility on the toilet by an anonymous person around 9 p.m., that night. The QIDP stated she was angry that Client 1's health and safety was compromised by the morning staff. The QIDP stated all of the staff was denying placing the client on the toilet and it was alleged that Staff T and Staff Q created a narrative of the incident in an effort to protect each other. The QIDP stated prior to this incident occurring there was no policy and procedure in place to ensure a head count was done and that none of the clients were left in the facility. The QIDP stated all of the staff played a role in Client 1 being left alone in the facility.
The undated facility's undated policy and procedure titled "Toileting," indicated clients will be toileted every 2 hours and monitored by staff at all times while in the bathroom.
The undated facility's policy and procedure titled "Abuse," indicated the clients shall remain free from abuse which includes neglect, and poor supervision.
The facility staff failed to:
1. Ensure Client 1 received proper care and treatment. Client 1 was left alone in the facility while seated on the toilet from 10 am until 3:30 pm, resulting in bruising to her buttocks and potential pain or tissue breakdown from poor circulation. Client 1 remained seated without staff prompting her to move. According to Staff T, she was responsible to care for Client 1. Staff T assisted the client with morning care then proceeded to do laundry.
2. Follow their policy for care and treatment, toileting and supervision.
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. |
| 960002060 |
RAYMOND HOUSE |
960013308 |
A |
11-Jul-17 |
GB6111 |
8690 |
Title 22 76918 Client?s Rights
(a) Each client shall have those rights as specified in Sections 4502through 4505 of the Welfare and Institutions Code and Sections 50500 through 50550 of Title 17 of the California Code of Regulations.
Welfare & Institution Code 4502.
(a) Persons with developmental disabilities have the same legal right 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 or be denied the benefits of, which receive 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:
(8) A right to be free from harm including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect.
An unannounced visit was made to the facility on March 30, 2017 at 5:45 a.m., to investigate an Entity Reported Incident (ERI), regarding Client 1 being left alone March 28, 2017, in the facility on the toilet for 5 hours and 30 minutes.
The facility failed to:
1. Follow their policy for abuse which indicated clients shall remain free from abuse which includes neglect, and poor supervision. Client 1 was left unsupervised/neglected alone in the facility while seated on the toilet from 10 am until 3:30 pm. According to Staff J, Staff T instructed Client 1 to go the bathroom and sit on the toilet. Client 1 remained on the toilet for 5 hours resulting in Client 1 receiving bruising to her buttocks and a high risk for potential pain or tissue breakdown from poor circulation.
During a review of the clinical record for Client 1 on March 30, 2017, the face sheet indicated Client 1 was admitted to the facility XXXXXXX 1999 with diagnoses that included: Downs syndrome (chromosome anomaly), profound intellectual disability (cognitive ability that is markedly below average level, incapable of self-care) and neurogenic bladder (minus nerve control of the bladder resulting in involuntary urination).
The Comprehensive Functional Assessment (CFA) dated October 6, 2015, indicated Client 1 required staff assistance for activities of daily living (ADL).
A review of the Occupational Therapist (OT) (people who are designated to help clients participate in the things they want and need to do through the therapeutic use of everyday activities) evaluation/ assessment dated October 7, 2016, indicated Client 1 was non-verbal, inconsistently followed simple directions, and was ambulatory, but sometimes did not want to walk and needed encouragement. The OT evaluation further indicated Client 1 wore adult diapers, but was able to use the toilet, and needed improvement in all activities of daily living.
A review of the Physical Therapy (PT) (work with patients to help them regain movement) evaluation/assessment dated September 28, 2016, indicated Client 1 requires staff assistance for functional ambulation and will remain sedentary without prompts from staff to move. Client 1 required balance assistance of staff, prefers hand held assistance and required one person assistance to stand.
A review of the Annual Individual Service Plan, dated October 12, 2016, indicated Client 1 weighed 98 pounds and wore eye glasses for distance. Client 1 who had no safety awareness, had no family involvement since placement, she had no comprehension of money and unable to make purchases.
During an observation of Client 1, on March 30, 2017 at 6:10 am, there was reddish circular bruising on her buttocks area in the shape of the toilet seat.
During an interview with Staff T, on March 30, 2017 at 6:15 am, she stated on the morning of March 28, 2017, she was assigned to provide care for Client 1. Staff T stated she showered, dressed, and fed Client 1. Staff T stated after providing activities of daily living (ADL), she sat Client 1 on the sofa and proceeded to do the laundry. Staff T stated the bus arrived and she and Staff Q placed all the clients except Client 1 on the bus. Staff T stated she assumed Staff J assisted Client 1 on the bus. Staff T stated she did not put Client 1 on the toilet and Staff J was responsible for cleaning the bathrooms when the clients leave for the day program. Staff T stated she was not scheduled to work that afternoon but after 3:30 pm, she received a phone call from Staff Q who informed her that when she arrived to the facility she found Client 1 seated on the toilet, and alone in the facility. Staff T stated she went to the facility to make sure Client 1 was okay. Staff T stated she observed Client 1 having a large red circular mark on her bottom after Staff Q removed her from the toilet.
Staff T stated she attempted to notify the administrative staff which included the administrator, and house leader, but she did not speak with anyone regarding Client 1 being found on the toilet and being left alone. Staff T stated the qualified intellectual disabilities professional (QIDP) called her at 9 pm that night, informing her that leaving the client on the toilet and alone was grounds for termination. Staff T stated she took full responsibility for Client 1 being left in the facility because she was assigned to provide care for Client 1 that day and she did not make sure the client was placed on the bus.
During an interview with Staff J, on March 30, 2017 at 7:03 am, she stated the morning of March 28, 2017, she did not take care of Client 1. Staff J stated she did not feed, bathe, or toilet her and that she heard Staff T tell Client 1 to go to the restroom. Staff J stated she cleaned and mopped the hallway and cleaned both bathrooms after the clients left, but did not see Client 1 on the toilet. Staff J stated Staff T was responsible for Client 1 that morning and for Client 1 staying on the toilet from 10:00 am until 3:30 pm (5 hours and thirty minutes).
During an interview with Staff Q, on March 30, 2017 at 11:45 am, she stated she and Staff T assisted 5 clients on the bus and after the 5 clients were boarded on the bus, she clocked out for the day. Staff Q stated when she arrived, at 3:15 pm, she waited around in the living room area, but at 3:30 pm, she went into the bathroom and was frightened to see Client 1 on the toilet. Staff Q stated she called Staff T and informed her that someone left Client 1 on the toilet alone in the facility. Staff Q stated she did nothing else; she did not call the administrator or the HL. Staff Q reiterated, "I did not do anything."
During an interview with the house leader (HL), on March 30, 2017 at 9:10 am, she stated Staff Q, Staff J, and Staff T did not notify administration that Client 1 had been left at the facility alone on the toilet. The HL stated she was concerned that staff did not take ownership for who placed the client on the toilet.
During an interview with the QIDP, on March 30, 2017 at 1:45 pm, she stated she was informed of the incident regarding Client 1 being left alone in the facility on the toilet by an anonymous person around 9 p.m., that night. The QIDP stated she was angry that Client 1's health and safety was compromised by the morning staff. The QIDP stated all of the staff was denying placing the client on the toilet and it was alleged that Staff T and Staff Q created a narrative of the incident in an effort to protect each other. The QIDP stated prior to this incident occurring there was no policy and procedure in place to ensure a head count was done and that none of the clients were left in the facility. The QIDP stated all of the staff played a role in Client 1 being left alone in the facility. The QIDP further stated the incident was not reported to the nurse.
The facility's undated policy and procedure titled "Toileting," indicated clients will be toileted every 2 hours and monitored by staff at all times while in the bathroom.
The undated facility's policy and procedure titled "Abuse," indicated the clients shall remain free from abuse which includes neglect, and poor supervision.
The facility staff failed to:
1. Follow their policy for Abuse which indicated clients shall remain free from abuse which includes neglect, and poor supervision. Client 1 was left unsupervised, neglected, and alone in the facility while seated on the toilet from 10 am until 3:30 pm, resulting in bruising to her buttocks (and potential1 and failed to ensure Client 1 was placed on the bus.
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. |
| 910000071 |
ROYALWOOD CARE CENTER |
910013608 |
AA |
9-Nov-17 |
QOBE11 |
20075 |
?483.25 Quality of Life
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.
?483.13 (c) Staff Treatment of Residents
F224
The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
?488.301 Definitions
Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.
?483.10 (b) (11)-Notification of Changes
F157
(b)(11)(i) A facility must immediately inform the resident; consult with the resident?s physician; and if known, notify the resident?s legal representative or an interested family member when there is?
(B) A significant change in the resident?s physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
On 1/13/17, an unannounced investigation was conducted at the facility after the Department received a complaint on 1/3/17, alleging a resident (Resident 1) had a seizure with a change in condition and there was hours-long delay in transporting the resident to the hospital on 7/4/16.
Based on interview and record review, the Department determined that the facility failed to provide Resident 1 with the necessary care and emergency services to attain or maintain the highest practicable physical, mental, and psychosocial well-being when the resident?s condition changed, including but not limited to:
1. Failure to provide the necessary care and services to Resident 1 when there was a change in the resident?s condition, including calling the appropriate emergency transportation services.
2. Failure to closely monitor Resident 1?s condition after she had a change in condition and the oxygen level had decreased.
3. Failure to follow the facility?s policy regarding providing emergency care and services and waited for over an hour for an ambulance transport service to transfer the resident to the hospital instead of calling 911 emergency services.
These deficient practices resulted in a critical delay in care, diagnosis, and treatment for Resident 1, and ultimately caused her death. The resident needed resuscitation (the action or process of reviving someone from unconsciousness or apparent death) by the BLS (Basic life support) emergency medical technicians (EMTs) immediately upon their arrival. After the resident?s heart stopped, the BLS had to call 911 for Emergency Advanced Cardiac Life Support (ACLS) emergency medical technicians for a higher level of care due to the resident?s critical condition. Resident 1 was transferred to the general acute care hospital (GACH) two hours and ten minutes after she was observed to have a change in condition. At the GACH Emergency Department, the resident was intubated (medical procedure in which a tube is inserted into the trachea [windpipe] to allow for ventilation [oxygen exchange]), placed on life support and admitted to intensive care. Resident 1 expired five days later on 7/9/16.
A review of Resident 1's Admission Record indicated the resident was an 82 year-old female who was initially admitted to the facility on 4/13/16 and re-admitted on 5/29/16. Resident 1's diagnoses included systemic lupus erythematosus (disease where body attacks its own healthy tissues), shortness of breath (SOB), tachypnea (abnormal rapid breathing), unspecified convulsions, and atrial fibrillation (irregular heartbeat).
A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment and care-screening tool) dated 4/20/16, indicated Resident 1 had the ability usually to understand and be understood by others. Resident 1 had moderate cognitive impairment (poor decisions, cues with supervision required) with a Brief Interview for Mental Status ([BIMS] a mental status assessment) score of 99 (which indicated the resident was unable to complete the interview). Resident 1 required total assistance in all activities of daily living (ADLs). According to the MDS, Resident 1 had dysphagia (difficulty in swallowing) and required the use of a feeding tube (gastrostomy tube [G-tube], a tube placed surgically into the stomach to provide nutrition and hydration).
A review of Resident 1's Initial Nursing Assessment, dated 4/14/16, indicated the resident was confused and had unclear speech. The assessment indicated Resident 1 had a productive cough (cough that expels a thick liquid) and required the use of a hand-held nebulizer (a device used to deliver medication into the lungs) or respiratory care needs.
A review of Resident 1?s physician?s orders, for May, June, and July 2016, indicated the resident was receiving Haldol (antipsychotic) 2 milligram (mg) three times a day starting May 26, 2016 until June 7, 2016; then decreased to 2 mg every day for seven days. Risperdal (antipsychotic) was started on June 13, 2016, 1 mg every day, receiving both antipsychotics, Haldol and Risperdal concurrently for two days via the G-tube.
A review of DailyMed, an online drug reference site, indicated a black box WARNING for the use of Haldol. ?Increased Mortality in Elderly Patients with Dementia-Related Psychosis.? Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. The causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Cardiovascular Effects Cases of sudden death have been reported in patients receiving haloperidol, and was contraindicated to administer to patients with heart conditions. In addition, Risperdal, the reference indicated elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. RISPERDAL? is not approved for use in patients with dementia-related psychosis. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=6cf978f3-4945-4624-a103-b800837101a2
A review of the Initial Nursing Assessment, following Resident 1's re-admission to the facility, dated 5/26/16, indicated the resident had seizure disorder (a disorder causing periodic loss of consciousness with or without convulsions).
A review of Resident 1's Discharge Summary, dated 7/4/16, indicated the resident was being transferred to the general acute care hospital (GACH) for further evaluation of abnormal laboratory results.
A review of a Physician's Order, dated 7/4/16, and timed at 6 p.m., indicated to transfer Resident 1 to the GACH for further evaluation.
A review of Resident 1's Patient Transfer Record, dated 7/4/16 without a time, indicated the reason for Resident 1's transfer included worsening blood urea nitrogen ([BUN] test that reveals how well the liver and kidneys are functioning), creatinine ([Creat] test to determine how kidneys are functioning normally), brain (B-type) natriuric peptide ([BNP] a test to indicate how well the heart is working), and lethargy (drowsy/sluggish).
A review of Resident 1's laboratory results, dated 7/2/16, and timed at 12:18 p.m., indicated Resident 1?s BUN level was elevated at 74 mg/dl (normal reference range [NRR] is 7-25 milligrams (mg) per deciliter (dL), creatinine level was elevated at 2.32 (NRR 0.60 - 1.20 mg/dl), and a BNP level elevated at 2688 (NRR of 1-100 picograms (pg) per milliliter (ml).
A review of Resident 1?s BNP results, dated as far back as 5/21/16, indicated the resident?s BNP was elevated at 932.0 pg/ml.
A review of Resident 1's Skilled Nursing Progress Note, dated 7/2/16, and timed at 5:05 p.m., indicated Resident 1 was stable during the shift, had no nausea or vomiting or complaint of pain/discomfort.
A review of a ?Change in Condition Progress Note,? dated 7/4/16, and timed at 4:43 p.m., indicated Resident 1 was having shortness of breath (SOB) with wheezing (whistling sound during breathing) during expiration (breathing out). A routine breathing treatment was administered, and wheezing and SOB decreased. The note indicated the physician was notified of the resident?s change in condition on 7/4/16 at 1:30 p.m. Resident 1?s family member (FM 1) was notified in person on 7/4/16 at 3 p.m.
A review of a ?General Progress Note,? dated 7/4/16, and timed at 9:51 p.m., written by Registered Nurse 2 (RN 2), indicated at 5:10 p.m. on that day, the resident?s family member (FM 1) informed RN2 that she noticed Resident 1's tongue was sticking out with her mouth open. The note indicated RN 2 went to check the resident and Resident 2 appeared to be sleeping with her mouth open and tongue slightly visible toward the right side of the mouth. Resident 1?s chin was observed with nodding movements. According to the note, RN 2 called Resident 1's physician at 5:30 p.m. on 7/4/17, and the physician returned the call at 6 p.m. the same day. The physician ordered Resident 1 to be transferred to the GACH due to worsening laboratory results. The basic life support ([BLS] EMTs [emergency medical technicians]) ambulance transport arrived at the facility at 6:25 p.m., one hour and fifteen minutes after RN 2 was alerted by FM 1 of Resident 1?s change in condition.
According to the ?General Progress Note,? while waiting for paperwork, one of the BLS EMTs took Resident 1's vital signs and asked the facility?s staff to give oxygen to the resident because the resident?s oxygen level was lower than what the facility?s staff had reported to them. The BLS EMT noticed Resident 1 had turned pale and informed the staff that he thought the resident was coding (term used when a person goes into cardiopulmonary arrest [heart stops beating]). Cardiopulmonary resuscitation ([CPR] act of providing chest compressions and breathing) was started immediately after the BLS EMTs were not able to get a pulse (heart rate), at the same time 911 ACLS EMTS were called at 6:45 p.m. The note indicated Resident 1?s pulse and breathing were restored after six rounds of 30 chest compressions and oxygen was delivered. The resident was transferred to the GACH via 911 emergency services at 7:20 p.m., 2 hours and 10 minutes after the family member (FM1) reported a change in the resident?s condition.
On 1/13/17, at 3:15 p.m., during an interview, RN 1 stated Resident 1 was non-verbal, received tube feedings, and received laboratory tests frequently because of high BUN and creatinine levels. RN 1 stated they sent Resident 1 to the GACH, but she could not remember the reason. RN 1 stated the resident stopped breathing and they had to initiate CPR and call 911.
During an interview on 1/13/17 at 3:25 p.m., RN 2 stated on the day of the incident (7/4/16), FM 1 stated something was wrong with Resident 1. RN 2 stated she observed Resident 1's body relaxed, but her lower jaw was twitching so they called the physician and checked her vital signs (temperature, pulse rate, rate of breathing, and level of blood pressure). RN 2 stated the physician ordered the resident to be transferred to the GACH via basic ambulance service because her vital signs were stable. RN 2 stated the ambulance took less than an hour to arrive to the facility and while giving report the EMT, Resident 1's oxygen saturation ([O2 sat] amount of oxygen in the blood) was low and the EMT asked her to give the resident oxygen. RN 2 stated the other BLS EMT stated that he thought Resident 1 was coding (heart/respiration arrest) and was not breathing, and they then started CPR right away. RN 2 stated the resident was pale at that time, they gave the resident 15 liters per minute (L/m) of oxygen and started chest compressions, when Resident 1 began breathing on her own. RN 2 stated Resident 1 had a pulse when she was transferred to the GACH. RN 2 stated Resident 1 did not have a seizure (uncontrollable shaking of the body). RN 2 stated Resident 1 never had seizures during her stay at the facility. RN 2 stated when she called the physician and informed him of Resident 1?s twitching of the resident?s lower jaw, he said to transfer the resident to the GACH because her labs were not good. RN 2 stated Resident 1 was breathing when the paramedics arrived, but had a low oxygen (O2 sat of 84 percent [%] (NRR 95-100%) and they placed the resident on 5 L/m of oxygen.
During an interview on 1/13/17 at 3:30 p.m., Licensed Vocational Nurse 1 (LVN 1) stated on 7/4/16, Resident 1 began having seizure-like movements. LVN 1 stated they called Resident 1's physician and he gave an order for the resident to be transferred to the GACH by regular ambulance because her vital signs were stable. LVN 1 stated when the ambulance arrived, they noticed during the report, Resident 1?s heart stopped and they started CPR and called 911. LVN 1 stated the resident?s skin color was pale and her whole body was shaking. LVN 1 stated Resident 1 was receiving Depakote (anti-seizure medication) routinely for agitation.
A review of Resident 1's Physician's Order, dated 5/26/16, indicated the resident was receiving Valporic acid (generic name for Depakote) capsule delayed release 125 mg via G-tube two times a day for agitation.
A review of a Physician's Order, dated 5/25/16, indicated to monitor seizure activity every shift and notify the physician.
During a telephone interview on 2/16/17 at 10:22 a.m., FM 1 stated that on 7/4/16, Resident 1 had a palpable (able to be touched or felt) seizure and she had to call out for help to the nurses, because the nurses would not come. FM 1 stated the head nurse on duty (RN 2) came into Resident 1's room and stated the resident was not having a seizure. FM 1 stated the nurse finally agreed to call 911 to transfer the resident to the hospital. FM 1 stated she left Resident 1?s bedside to drive to the GACH, so she could be there at the time Resident 1 arrived. After an hour of waiting at the GACH, FM 1 stated she called the facility and was told Resident 1 stopped breathing and they called 911. FM 1 stated after the resident arrived to the GACH, they found food in the resident?s throat and she had the wrong identification wristband on her arm. FM 1 stated Resident 1 had no prior history of seizures.
A review of Resident 1?s EMS (emergency medical services) Report, dated 7/4/17, documented by the ACLS EMTs, indicated the paramedics found the resident lying in bed altered (change in mentation [mental status]). The report indicated the staff informed the ACLS EMTs (paramedics) that the resident was being prepped for a transfer to the GACH by an ambulance company (BLS EMTs). The paramedics documented they found Resident 1 pulseless and apneic (not breathing) and pale after receiving six rounds of CPR.
A review of Resident 1's GACH records indicated upon arrival to the emergency department (ED), on 7/4/16 at 7:27 p.m., Resident 1 was bradycardic (slow heart rate) and had what appeared to be G-tube feeding formula in her mouth. Resident 1 was emergently intubated (medical procedure in which a tube is inserted into the trachea [windpipe] to allow for ventilation) and admitted to the intensive care unit (ICU) and continued on mechanical ventilation.
A review of the ED Physician?s Note, dated 7/4/16, and timed at 8:53 p.m., indicated it was unclear if Resident 1 truly had a seizure as reported by FM 1, but the staff at the nursing home did not feel it was a seizure. The ED note indicated, per FM1, Resident 1 continued having difficulty breathing and 911 was not called, but arrangements were made for an inter-facility transfer to the hospital. According to the note, when the transfer team (BLS EMTs) arrived, the patient (Resident 1) was found not to be breathing very well and they could not feel pulses. CPR was initiated and the resident received chest compressions and bagging ([BVM] bag valve mask, [Ambu-bag] a hand-held device commonly used to provide positive pressure ventilation for breathing) and apparently had a spontaneous return of circulation. 911 was called and the patient was transported to the GACH.
According to the GACH?s history and physical (H/P) for Resident 1, dated 7/6/16, the physician discussed the resident?s poor prognosis with the resident?s family, specifically the abnormal EEG ([electroencephalogram] a test for brain activity) findings indicating diffuse suppression of the brain wave activity suggestive of severe anoxic (lack of oxygen) brain injury. The H/P indicated the resident?s family and her healthcare decision maker under POA (power of attorney) would proceed with comfort care (end-of-life care involving relieving symptoms and pain rather than treating underlying medical conditions).
A review of the GACH's Death Summary, dated 2/28/17 and timed at 7:19 p.m., done by the physician, indicated Resident 1 was extubated (removal of a tube inserted into the trachea) on 7/8/16, and was pronounced deceased on 7/9/16 at 1:25 a.m.
A review of the facility's policy and procedure titled, "Seizure Precautions," revised on 1/2/14, indicated to review the history with patient and/or health care decision maker regarding patient's seizures including any specific characteristics or conditions that precipitate seizures. Identify patient-specific interventions and update care plan. If a patient had a seizure, monitor patient's vital signs and mental status every 30 minutes for two hours, notify physician and family, and suction if needed.
A review of the facility's policy and procedure titled, "Emergency: Medical Response," revised on 7/17/14, indicated to respond to the identified emergency by performing the following:
1. Evaluate the patient
2. Initiate appropriate medical intervention (CPR, burns, bleeding, seizures, choking, etc.)
3. Obtain automated external defibrillator ([AED] electronic device that analyzes the heart's rhythm), if applicable, emergency cart, emergency drug box
4. Monitor vital signs
5. Call physician/mid-level provider and family
6. Call 911, as appropriate
A review of Resident 1?s death certificate indicated the resident expired on 7/9/16 at 1:25 a.m. The immediate cause of death was listed as anoxic brain injury-non-traumatic (results as a major lack of oxygen to the brain); cardiopulmonary arrest (results due to a major lack of oxygen to the brain) ; aspiration pneumonia (occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs, instead of being swallowed into the esophagus and stomach) ; and senile dementia (brain diseases that cause a long term and often gradual decrease in the ability to think and remember).
Based on interview and record review, the Department determined that the facility failed to provide Resident 1 with the necessary care and emergency services to attain or maintain the highest practicable physical, mental, and psychosocial well-being when the resident?s condition changed, including but not limited to:
1. Failure to provide the necessary care and services to Resident 1 when there was a change in the resident?s condition, including calling the appropriate emergency transportation services.
2. Failure to closely monitor Resident 1?s condition after she had a change in condition and the oxygen level had decreased.
3. Failure to follow the facility?s policy regarding providing emergency care and services and waited for over an hour for an ambulance transport service to transfer the resident to the hospital instead of calling 911 emergency services.
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 or mental harm would result, and were a direct proximate cause of death for Resident 1. |
| 940000023 |
REGENCY OAKS POST ACUTE CARE CENTER |
940013541 |
A |
12-Oct-17 |
K1ML11 |
15271 |
F329
?483.45(d) Unnecessary Drugs?General.
Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-
?483.45(d)(1) In excessive dose (including duplicate drug therapy); or
?483.45(d)(2) For excessive duration; or
?483.45(d)(3) Without adequate monitoring; or
?483.45(d)(4)Without adequate indications for its use; or
?483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
The Department received a complaint on 6/20/17 alleging a resident (Resident 1) was overdosed on pain medications and taken to the emergency room. An unannounced complaint investigation was conducted on 9/6/17.
The facility failed to ensure that Resident 1's drug regimen was free from unnecessary drugs, including but not limited to:
1. Failure to ensure Resident 1, who had respiratory problems, was free of unnecessary drugs, such as excessive amounts, in duplicated dosages.
2. Failure to ensure medications given were prescribed by the physician.
3. Failure to ensure accurate documentation of narcotic medications.
4. Failure to adequate assess Resident 1 for adverse reaction of the medications.
This deficient practice resulted in Resident 1 receiving excessive amounts of narcotics (a drug that in moderate doses dulls the senses, relieves pain) and psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications without a physician?s order and adequate monitoring and in the presence of adverse consequences. Resident 1 had difficulty to be aroused, resulting in a transfer to a general acute care hospital (GACH) for evaluation and treatment of a drug overdose.
A review of Resident 1's Admission Face sheet, indicated Resident 1 was a 53 year-old female who was admitted to the facility on June 16, 2017. Resident 1's diagnoses included chronic obstructive pulmonary disease ([COPD], a lung disease characterized by constriction of the airways and difficulty or discomfort in breathing), dorsalgia (pain in the upper back), fibromyalgia (widespread muscle pain, fatigue, and multiple tender points) major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest), and anxiety disorder (excessive worry or fear).
A review of Resident 1's Minimum Data Sheet (MDS), a standardized assessment and care screening tool, dated June 18, 2017, indicated Resident 1's cognition (thought process) was intact, he was independent in decision-making skills and did not have any memory problems.
A review of Resident 1's Clinical Health Status Admission Assessment, indicated the resident was admitted to the facility for pain management and was awake and alert. The assessment indicated Resident 1 had a history of shortness of breath with difficulty breathing.
A review of Resident 1 physician?s telephone orders, dated June 16, 2017, and timed at 11:30 p.m., indicated the following medications were prescribed:
A. Oxycodone (a strong control narcotic medication used to relieve pain) 15 milligrams (mg) every six hours as needed for pain.
B. Clonazepam ([benzodiazepine] a medication used to prevent and treat seizures, panic disorder as an anti-anxiety, and akathisia [feeling of restlessness and urge to move]) 1 mg three times a day as needed (PRN [whenever needed]) for akathisia.
C. Baclofen (a muscle relaxing medication that is used to treat muscle spasms) 10 mg three times a day as needed for muscle spasms.
D. Baclofen 20 mg at bedtime for muscle spasms.
E. Gabapentin (a medication used to treat seizures and nerve pain) 1200 mg twice a day for nerve pain.
A review of Resident 1's Controlled Drug Record indicated Resident 1 received Clonazepam 1 mg on the following dates and times for a total of three doses on June 17, 2017 at 5 p.m., and at 9 p.m., and on June 18, 2017 at 9 a.m.
A review of Resident 1's Medication Administration Record (MAR) for the month of June 2017 indicated the resident received Clonazepam 1 mg on the following dates and times: June 17, 2017 at 2 p.m. and June 18, 2017 at 9 a.m., for a total of two times, which did not coincide with the controlled drug record of three doses.
A review of Resident 1's Controlled Drug Record indicated Resident 1 received Oxycodone 15 mg on the following dates and time June 17, 2017 at 5 a.m., 11 a.m., 5 p.m., and at 11 p.m. and June 18, 2017 at 5 a.m., and 3 p.m., for a total of six doses.
A review of Resident 1's MAR for the month of June 2017 indicated the resident received Oxycodone 15 mg a total of five times on the following dates and times: June 16, 2017 at 5 a.m. and 11 p.m., June 17, 2017 at 11 a.m., June 18, 2017 at 5 a.m., and 3 p.m. The nurse's initials on the MAR indicated the medication was administered a total of four times.
A review of Resident 1's June 2017 MAR, indicated the resident received Gabapentin 1200 mg on the following dates and times: June 17, 2017 at 9 a.m., and 5 p.m., and on June 18, 2017 at 9 a.m., and 5 p.m. for a total of four times.
A review of Resident 1's June 2017 MAR, indicated the resident received Baclofen 20 mg on the following dates and times: June 17, 2017 at 9 a.m., and on June 18, 2017 at 8:15 a.m., and 11:30 a.m. for a total of three times. The nurse's initials on the MAR indicated the medication was administered a total of two times.
A review of Resident 1's ?Mood/Behavior/Psychosocial Wellbeing Care Plan,? dated June 16, 2017, indicated that diversional activities would be used to redirect the behavior and the resident would be monitored for side effects of the anti-anxiety medication Clonazepam.
A review of Resident 1's ?Alteration in Comfort Care Plan,? dated June 16, 2017, indicated the resident would be monitored for side effects of pain medications.
A review of Resident 1's ?Fall/Injury Potential Care Plan,? dated June 16, 2017, indicated the resident would be monitored for changes in level of alertness and/or increasing lethargy (drowsiness).
A review of a Nursing Note, dated June 17, 2017, and timed at 5 a.m., indicated the resident was alert and verbally responsive and Baclofen 10 mg was administered to the resident at 4 a.m.
A review of Resident 1's Nursing Note, dated June 17, 2017, and timed at 2:30 p.m., indicated the resident was administered Baclofen 10 mg at 2 p.m.
A review of Resident 1's Nursing Notes, dated June 17, 2017, and timed at 6:30 p.m., indicated the resident was administered Clonazepam and there was no vital signs (body temperature, pulse rate [heart rate], respiration rate, blood pressure; measurements of the body's most basic functions) documented.
A review of Resident 1's Nursing Notes, dated June 17, 2017, and timed at 9 p.m., indicated the resident requested and was administered another Clonazepam 1 mg, two and a half hours (not three times a day as ordered) after the prior administration of Clonazepam without vital signs assessed and/or documented.
A review of Resident 1's Nursing Note, dated June 18, 2017, and timed at 2 p.m., indicated the resident's pain was assessed as being 1 out of 10 pain (1 being the least and 10 being the worst pain) after receiving Norco (combination prescription drug acetaminophen/hydrocodone used to treat moderate to severe pain) at 11:30 a.m.
A review of Resident 1?s physician?s orders indicated there was no order for the resident to received Norco for pain.
A review of Resident 1's Nursing Note, dated June 18, 2017, and timed at 8 p.m., indicated the resident was alert and able to verbalize needs. The note indicated that all medications were given as ordered on June 18, 2017, which included:
1. Clonazepam 1 mg at 9 a.m.
2. Norco (no strength indicated) at 11:30 a.m.
3. Oxycodone 15 mg at 5 a.m. and 3 p.m.
4. Baclofen 10 mg at 8:15 a.m. and 11:30 a.m.
5. Gabapentin 1200 mg at 9 a.m. and 5 p.m.
According to the online site "Lexicomp" (provider of drug information and clinical content for the healthcare industry) the black box warnings for Clonazepam indicated that concomitant use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. The online drug information indicated to limit dosages and durations to the minimum required and follow residents for signs and symptoms of respiratory depression and sedation at https://online.lexi.com/crlsql/servlet/crlonline.
A review of Resident 1's Nursing Notes, dated June 18, 2017, and timed at 8:30 p.m., indicated the resident had a decreased level of consciousness and appeared to be very sleepy. The resident attempted to talk, but was unable. The note indicated the physician was notified and the paramedics were called. There was no documented evidence the resident?s vital signs were assessed.
A review of Resident 1's Nursing Notes, dated June 18, 2017, and timed at 9 p.m., indicated the paramedics arrived and "took over care of the resident."
A review of Resident 1's Nursing Notes, dated June 18, 2017, and timed at 10 p.m., indicated the resident was taken by paramedics to the hospital.
A review of Resident 1's ?Resident Transfer Record,? dated June 18, 2017 and untimed, indicated the resident was not verbally responsive and had a change in condition. The record indicated the resident's respirations ([respiratory rate] the action of breathing) was listed as 18 (normal reference range [NRR] is 12-20) and the resident was transferred to the hospital.
A review of the Paramedic's Emergency Medical Report, dated June 18, 2017, indicated the paramedics were dispatched at 2125 (9:25 p.m.). The report indicated the resident was observed with an altered level of consciousness (ALOC) with pinpoint pupils (abnormally small pupils resulting from a reaction to certain drugs). According to the report Resident 1?s respiratory rate was six and she was lethargic (state of sleepiness or deep unresponsiveness). Resident 1's Glasgow Coma Scale ([GCS] means of recording the conscious state of a person) indicated that the resident did not have any motor or verbal responses and only opened her eyes to pain. The Paramedics administered 2 mg of Narcan (a medication used to treat and reverse narcotic/opioid drug overdose) which resulted in Resident 1 returning to her baseline mental status. After the Narcan administration, Resident 1's GCS improved and the resident was able to spontaneously open her eyes, obey commands to move her body, but had some confusion.
A review of Resident 1's Emergency Department (ER) Records, dated June 18, 2017, and timed at 10:06 p.m., indicated the resident arrived to the emergency department via ambulance and presented with an accidental narcotic overdose. According to the ER note, Resident 1 denied taking any medications on her own.
A review of Resident 1's ER Notes, dated June 19, 2017, and timed at 12:07 p.m., indicated the resident refused to transfer back to the facility and stated that she did not feel safe at the facility.
On September 6, 2017 at 2:40 p.m., during a concurrent interview and record review, a Licensed Vocational Nurse 3 (LVN 3) stated the MAR and the Controlled Medication Record should match. LVN 3 stated she was not sure if Clonazepam affected one's respirations and she was unaware of any contraindications of administering Clonazepam and Oxycodone together.
On September 6, 2017 at 3:20 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated LVN 4 probably "forgot to document her administrations" of the medication Clonazepam. The DON stated LVN 4 should have initialed the front of the MAR and documented the administrations of the medication on the back of the MAR. The DON stated the MAR and Controlled Medication Sheets should match with the amount of medications given. The DON stated when giving Oxycodone and Clonazepam together she would be concerned about the resident's liver and kidney function. The DON stated she was not aware of any black box warning for administering pain medications with benzodiazepines. The DON verified that there was no order for Resident 1 to receive Norco pain medication.
On September 6, 2017 at 3:38 p.m., during a telephone interview, the facility's Pharmacist Consultant (PC) stated that when giving Oxycodone, Clonazepam, and Baclofen to a resident with COPD, the resident should be carefully monitored for level of sedation and respirations.
At 3:55 p.m., on September 6, 2017, during a telephone interview, LVN 2 stated Resident 1 had increased sedation on the day of the incident (June 18, 2017) and would only open her eyes, but was unable to talk. LVN 2 stated, "I called another nurse over and we assessed (Resident 1) and then called the paramedics."
According to an online site "Lexicomp" (provider of drug information and clinical content for the healthcare industry) the black box warnings for Oxycodone indicated users were exposed to the risks of opioid addiction, abuse, and misuse, which could lead to overdose and death. It also indicated concomitant use of opioids with benzodiazepines or other CNS depressants, could result in profound sedation, respiratory depression, coma, and death. Concomitant prescribing of oxycodone and benzodiazepines or other CNS depressants was to be reserved for use in patients for whom alternative treatment options are inadequate. The online drug information indicated to limit dosages and durations to the minimum required and follow residents for signs and symptoms of respiratory depression and sedation at https://online.lexi.com/crlsql/servlet/crlonline.
A review of the facility's policy and procedures titled, "Medication Administration-General Guidelines," and dated April 2008, indicated that if a dose seemed excessive for the resident's age or condition, the nurse was to call the prescriber or the pharmacy for clarification. The policy indicated that the nurse was to record the administration on the residents MAR directly after a medication was given by initialing on the line specific to the dose given. As needed medications required additional documentation such as the reason the med was given and the results that were achieved after the dose was given.
A review of the facility's policy and procedures titled, "Pain-Clinical Protocol," with a revision date of April 2009, indicated that staff would monitor residents for adverse effects of pain medications, which the facility failed to follow.
The facility failed to ensure that Resident 1's drug regimen was free from unnecessary drugs, including but not limited to:
1. Failure to ensure Resident 1, who had respiratory problems, was free of unnecessary drugs, such as excessive amounts, in duplicated dosages.
2. Failure to ensure medications given were prescribed by the physician.
3. Failure to ensure accurate documentation of narcotic medications.
4. Failure to adequate assess Resident 1 for adverse reaction of the medications.
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. |
| 920000088 |
RINALDI CONVALESCENT HOSPITAL |
920013484 |
B |
18-Sep-17 |
WPGE11 |
15776 |
?CFR 483.60 (i) (1)-(3) Food Procure, Store/Prepare/Serve - Sanitary
(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
On August 21, 2017, at12:25 p.m., during an unannounced recertification survey visit, an inspection of the kitchen was conducted.
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by failing to:
1. Store food in a safe manner when using a malfunctioning freezer and not monitoring the freezer temperature.
2. Ensure the two-sink compartment for manual dishwashing was used according to the facility's policy and procedures to ensure disinfection of washed dishes.
3. Ensure the dry food was stored at temperatures that maintained food quality, nutrient content, and control of bacterial growth.
4. Ensure safe thawing procedures were followed as indicated in the facility?s policy.
As a result, the total census of 90 residents was placed at risk of foodborne illness, 87 residents received oral diets and three residents received tube feeding but were administered water from water pitchers washed in the kitchen.
Nursing home residents risk serious complications from food borne illness as a result of their compromised health status. Symptoms of food borne illness include diarrhea, vomiting, headaches, fever, and confusion, loss of appetite, abdominal cramping and pain. When those conditions persist they can lead to dehydration and may require hospitalization and in some cases death.
The beef and dairy products (ice cream) are considered time/temperature control for safety foods (formerly called "potentially hazardous foods") and were stored in the food danger zone.
"The food danger zone refers to temperatures above 41øF and below 135øF that allow the rapid growth of disease causing microorganisms that can cause foodborne illness. Foods held in the danger zone for more than six hours (if cooked and cooled) may cause a foodborne illness if consumed" (Center for Medicare and Medicaid, State Operations Manual).
An immediate jeopardy was called on August 21, 2017, at 7:20 p.m. The facility was notified of the immediate jeopardy situation. A plan of correction was received, verified acceptable, and the IJ was abated on August 24, 2017, at 1:57 p.m.
Findings:
1. On August 21, 2017, from 12:25 p.m. to 2:27 p.m., during the initial kitchen observation with the Dietary Service Supervisor (DSS) and Dietary Aide 1 (DA 1), the freezer external liquid crystal display (LCD) panel temperature had a reading indicating ?Def? for defrost. The freezer reading of a thermometer located inside the freezer read over 70øF. At 2:15 p.m., the external LCD panel thermometer had a reading of 35øF. The inside freezer mechanical temperature was greater than 70øF.
The freezer contents were as follows:
- There were several boxes of three ounces (oz.) ice cream cups of multiple flavors with temperatures ranging from 22øF to 47.8øF. The boxes label indicated to keep frozen from -10øF to -20øF.
- Two three-gallon containers of ice cream with a temperature of 45.7øF and 41.9øF.
- A10-pound bag of boneless and skinless chicken leg meat with a temperature of 23.2øF.
- A five-pound bag of whole chicken legs with a temperature of 23.9øF.
- A 10-pound bag of boneless chicken with a temperature of 23.5øF.
- Four boxes of chicken with temperatures ranging from 21.2øF to 28.4øF.
- A 10-pound pork in a box with a temperature of 20.8øF.
- Two packs of hash browns with 10 patties each inside with temperature ranging from 52.7øF to 54.1øF.
- Two five-pound mechanically separated turkey with temperature of 28.9øF and 37.4øF.
- A two-pound bag and a four-pack bag of two-pound sliced oven roasted turkey breast with temperature ranging from 46.9øF of 48.2øF.
- A box of 10-pound of steak opened on June 6, 2017 with a temperature of 50.2øF.
- A 16-inch cheese pizza with nine counts/pieces with 42 oz. each in a box had a temperature of 43.7øF. The pizza box indicated keep frozen.
- A 12-pound bag of sliced turkey bologna with a temperature of 44.4øF.
- A five-pound bag of cookie dough with a temperature of 50.2øF.
The bottom of the freezer was soaked with red liquid (from the meat) mixed with white and yellow liquid (from the melted ice cream).
A review of the freezer temperature log dated August 2017, indicated on August 20, 2017 and August 21, 2017, the log was blank. The last time the temperature was checked was on August 19, 2017, at 6 p.m. with a temperature of -2øF.
On August 21, 2017, at 12:45 p.m., during an interview, the Environmental Services Director (ESD) stated yesterday (August 20, 2017) at approximately 1:30 p.m., the vents in the freezer got frozen, he cleaned them, and the freezer was working. The ESD stated he did not take the temperature of the freezer. Today (August 21, 2017), at 8 a.m., the freezer was in defrosted mode and he called the technician.
On August 21, 2017, at 1:10 p.m., during observation and concurrent interview, Cook 1 took two hamburger patties from the freezer and explained a resident wanted to have a hamburger. Cook 1 took the patties temperatures, one was 48.2øF and the other was 63.1øF and proceeded to cook the hamburger on the stove top.
On August 21, 2017, at 2:15 p.m., during an interview, DA 1 stated Cook 1 was responsible to check the refrigerator and freezer temperatures.
On August 21, 2017, at 2:20 p.m., during an interview, Cook 1 stated the day prior (Sunday, August 20, 2017), the freezer was not working, she did not log the daily temperature because the freezer was broken, and she informed the DSS of the broken freezer. Cook 1 also stated the broken freezer was the only freezer in the facility. When asked how she checked the temperature of the freezer, Cook 1 stated she looks at the outside and the inside thermometers. When asked what the external reading of the freezer was, she stated it was 35.5øF (when it read ?Def?).
On August 21, 2017, at 2:25 p.m., during an interview, the DSS stated she did not inform the Administrator regarding the malfunctioning freezer.
On August 21, 2017, at 4 p.m., during an interview, the Administrator, he stated he was not aware of the problem with the freezer.
According to the Food Code U.S. Public Health Service [U.S. Department of Health and Human Services, Public Health Service, Food and Drug Administration 2013], indicated under food temperature control, frozen food is solid to the touch. The freezer equipment should be designed and maintained to keep foods in the frozen state. Corrective action should be taken if the storage or display unit loses power or otherwise fails. Raw or ready-to-eat foods or commercially processed bulk-pack food that is packaged on-site presents a greater risk of cross-contamination. Additional product handling, drippage during the freezing process, partial thawing or incomplete seals on the package increase the risk of cross-contamination from these products packaged in-house. Under parasite destruction on freezing, except as specified in the paragraph of this section, before service or sale in ready-to-eat form, raw-marinated, partially cooked, or marinated-partially cooked fish shall be frozen and stored at a temperature of -20øC (-4øF) or below for a minimum of 168 hours (seven days) in a freezer.
The facility's undated policy and procedure titled "Procedure for Freezer Storage", indicated frozen foods should be immediately stored in the freezer upon delivery. The freezer should be maintained at a temperature of 0øF to -10øF. Freezer temperatures should be recorded twice daily. Temperatures are to be recorded upon opening and closing of kitchen by a designated employee and logged in the Sanitation Section, page 8.3. All frozen food should be labeled and dated. Frozen food should be left in the refrigerator to thaw.
2. On August 22, 2017, at 11 a.m., during an observation accompanied by the DSS, DA 4 and DA 1 were manually washing the plate covers in a two-compartment sink. DA 4 got hot water, using a bucket, from the faucet of the other compartment sink which was used for raw food. DA 4 explained there was no hot water coming out from the faucet at one side of the sink because the plumber turned the water off while working on the heater. The plate covers were placed first in the sink then the hot water was placed gradually. The temperature of the hot water from the faucet was 135øF. DA 1 put soap on the plate covers, then put them in the other sink which had sanitizer with water but the level was low and did not cover the plate covers; the plate covers were floating and not submerged in the water with sanitizer. Then, without rinsing, the plate covers were placed in the dish rack. When DA 4 performed the chlorine testing, he dipped the testing strip it in the solution of water and not on the dish surface. The result was 200 ppm. The plate covers were not rinsed with hot water.
A review of the Dish Machine Temperature and Sanitizing Agent Log dated August 2017 indicated the type of dishwashing machine was a low/energy saver machine with a minimum sanitizing agent of 50 ppm. The required temperature for the low temperature machine was 120-140øF and the rinse was no less than 120øF.
On August 22, 2017, at 11:15 a.m., during an interview with DA 1, he stated the strip test for chlorine should have been dipped on the dish and not on the solution.
On August 22, 2017, at 12:15 p.m., during an interview, the DSS stated the dishwashing machine was not working and she called the plumber the night prior, at 10 p.m.
A review of the facility's policy and procedure titled "Three Compartment Sink: Manual Washing, Rinsing, and Sanitizing", indicated to rinse, scrape, or soak all items before washing. Wash items in the first sink in a detergent solution. Water should be at least 110øF (43øC). Replace water when suds are gone or water is dirty. Immerse or spray-rinse items in the second sink. Water temperature should be 110øF (43øC). Remove all food and detergent traces. If using immersion method, replace water when it becomes cloudy or soiled. Immerse items in third sink in hot water of 180øF (82øC) or immerse in a chemical sanitizing solution. Manual sanitizing shall be accomplished in the third sink by one of the following methods. Use thermometers and chlorine/quaternary strips for monitoring. Immerse in a solution of 50 ppm available chlorine solution for seven seconds with water greater than 75øF, not to exceed 115øF. Immerse in hot water at least 180øF for 30 seconds. After sanitizing, place items on a drain board to air dry.
When a three-compartment sink is not available, a one or two-compartment sink maybe used following guides for temperature and sanitizing, and by using the Drain and Fill method. For example: after washing utensils in the first sink, rinse utensils in the second sink. Now drain the second sink, refilling it with a sanitizing solution. If needed, utilize another approved container, such as a bus tub, for one of the cleaning or sanitizing steps.
On August 22, 2017, at 12:25 p.m., during an interview with the Registered Dietitian (RD), she stated the water in the sink should have been drained to rinse the plate covers and the testing of the solution was not done as per policy.
3. On August 21, 2018, at 12:30 p.m., during an observation of the dry food storage area in the presence of the DSS, the thermometer in the room had a temperature reading of 78øF. At 2:25 p.m., the temperature was 82øF. A thermostat, near the dry food section, had a setting of 69øF but the temperature reading was 83øF.
On August 21, 2018, at 12:35 p.m., during an interview, the DSS stated they did not keep a log of the temperature in the dry food storage area.
According to the Proper Storage Temperatures for USDA Commodities (California Department of Education) http://www.cde.ca.gov: the correct temperature control is essential to maintain food quality, nutrient content, and control of bacterial growth. Daily monitoring of temperatures is necessary to ensure adequate storage conditions. Many items such as canned goods, baking supplies, grains, and cereals may be held safely in dry storage areas. The guidelines should be followed included to keep dry storage areas clean with good ventilation to control humidity and prevent the growth of mold and bacteria; store dry foods at 50 degrees Fahrenheit (øF) for maximum shelf life. However, 70øF is adequate for dry storage of most products. Place a thermometer on the wall in the dry storage area. Check the temperature of the store room daily.
The facility's undated policy and procedure titled "Storage of Food and Supplies", indicated food and supplies will be stored properly and in a safe manner. The storeroom should be well-lighted, well-ventilated, cool, dry, and clean at all times. Thermometers should be placed in all storage areas and checked frequently. Recommended temperature is 50 to 70øF (Maximum temperature of 80øF or re-evaluate cooling system).
4. On August 21, 2017, at 1:40 p.m., during the initial kitchen observation in the presence of the DSS, Cook 1 took roast beef from a malfunctioning freezer. The meat juices were dripping to the floor when transferring from the freezer to the tub over the sink. The temperature measured by the DSS was 32øF and when repeated, the temperature was 31.3øF. According to the DSS, the weight of the meat was between 18 to 20 pounds. The DSS stated she did not know how and for how long the meat was thawed.
The facility's policy and procedure titled "Thawing of Meats" dated March 2013, indicated thawing meat properly can be done in four different ways that included in a refrigerator at 41øF or colder. Allow two to three days to defrost, depending on quantity and total weight of meat. Use a drip pan under food being thawed so drippings do not contaminate other food. The other way was in a microwave, if foods are to be cooked immediately following the thawing process. Next is to submerge under running, potable water at a temperature of 70øF or lower, with a pressure sufficient to flush away loose particles. Fourth, foods can be thawed as part of the cooking process. Under the section of refrigerated storage and storage of frozen food, indicated store raw meat, poultry, and fish separately from cooked and ready-to-eat food to prevent cross-contamination. Estimated time for thawing meats is one day (24 hours) for every five pounds frozen meat in the refrigerator at approximately 40øF.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by failing to:
1. Store food in a safe manner when using a malfunctioning freezer and not monitoring the freezer temperature.
2. Ensure the two-sink compartment for manual dishwashing was used according to the facility's policy and procedures to ensure disinfection of washed dishes.
3. Ensure the dry food was stored at temperatures that maintained food quality, nutrient content, and control of bacterial growth.
4. Ensure safe thawing procedures were followed as indicated in the facility?s policy.
As a result, the total census of 90 residents was placed at risk of foodborne illness, 87 residents received oral diets and three residents received tube feeding but were administered water from water pitchers washed in the kitchen.
The above violation had direct or immediate relationship to the health, safety, or security of all 90 residents in the facility. |
| 910000003 |
ROSECRANS CARE CENTER |
910013593 |
B |
17-Nov-17 |
DM7X11 |
4579 |
? 483.12
(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95,
Based on interview and record review the facility failed to:
Follow its policy in notifying the Department of Public Health (DPH) timely, within 24 hours, of an allegation of staff abuse towards Resident 4.
This deficient practice had the potential to put Resident 4 at risk for harm and other residents at risk for abuse.
The Department received an entity reported incident (ERI) on 8/2/17, four days after an alleged abuse, of a resident (Resident 4) alleging she was hit by a Certified Nursing Assistant 1 (CNA 1).
On 8/16/17, an unannounced ERI investigation was conducted.
A review of Resident 4's Admission Face Sheet indicated the resident was
A 61 year-old female who was admitted to the facility on 1/30/15. Resident 4's diagnoses included quadriplegia (inability to move both arms and legs) and hypertension (high blood pressure).
A review of Resident 4's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 6/23/17, indicated Resident 4's cognition (ability to think) was severely impaired. The MDS indicated Resident 4 required limited to total assist with eating, toileting, dressing, and transfers.
A review of Resident 4's Investigation of Incident/Accident/Injury of Unknown Origin, dated 7/30/17, indicated Resident 4 reported being slapped on the stomach and yelled at by CNA 1. The form indicated Resident 4 was alert and oriented times three ([A&O x 3] alert to person, place, and time).
On 8/16/17 at 7:20 a.m., during an interview, a Registered Nurse 2 (RN 2) stated any alleged abuse incidents should be reported to the local Police Department and DPH within 24 hours.
On 8/16/17 at 8:40 a.m., during an interview, RN 3 stated if an abuse incident occurred during night shift, the Administrator and DPH should be notified within 24 hours.
On 8/16/17 at 9:02 a.m., during an interview, the Administrator stated the alleged incident occurred on 7/29/17 at 11:30 p.m. and DPH was notified on 7/31/17 (two days later). The Administrator stated if an alleged abuse occurred over the weekend and the involved resident had a diagnosis of dementia (a progressive loss of memory), only the police and ombudsman were to be notified. The Administrator stated the alleged incident happened in his absence and he asked the Director of Nursing (DON) to report the incident to DPH because at the time, the Administrator was not aware Resident 4 had dementia.
On 8/16/17 at 9:08 a.m., during an interview, the Administrator stated if he knew Resident 4 had dementia, the facility would not have called DPH and informed them of the incident.
On 8/16/17 at 9:32 a.m., during an interview, the DON stated the alleged incident should have been reported to DPH within 24 to 72 hours if it occurred during the weekend, which was contrary to the facility?s policy. The DON stated she was not in the facility the day the alleged abuse occurred and therefore could not report the incident to DPH within 24 hours.
On 8/16/17, at 2:14 p.m., during an interview, RN 1 stated she notified the DON of the alleged abuse the night of 7/16/17, via a text message, but the DON never responded.
On 8/16/17 at 2:23 p.m., during an interview, RN 1 stated she should have called the DPH hotline and reported the alleged abuse, but was instructed by RN 2 that the DON or Administrator were the ones to call DPH.
A review of the facility's policy titled, "Investigation and Reporting," updated on 1/20/17, indicated if the suspected abuse does not result in bodily injury, the mandated reporter must report the incident within 24 hours to the local ombudsman, the Licensing and Certification Program, and the local law enforcement agency. The policy indicated the facility had to orally notify the State Health Department and other regulatory agencies according to individual state reporting requirements.
Based on interview and record review the facility failed to:
Follow its policy in notifying the Department of Public Health (DPH) timely, within 24 hours, of an allegation of staff abuse towards Resident 4.
The above violation had a direct relationship to the health, safety, or security of the residents in the facility. |
| 250000073 |
Riverside PostAcute Care |
250013499 |
B |
21-Sep-17 |
ZK9P11 |
4822 |
F-226 CFR 42 483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations.
On May 31, 2017, at 9:15 a.m., an unannounced visit was made to the facility to investigate an entity reported incident of inappropriate conduct involving Resident A and another male resident which occurred on May 18, 2017.
While reviewing the record of Resident A regarding the reported incident of May 18, 2017, a previous incident of inappropriate touching was discovered documented in the nursing notes. The note dated March 27, 2017, at 11:07 p.m., indicated Resident A was observed "...fondling with another male resident inappropriately..." There was no documentation indicating who the other resident was involved in the incident.
There was no indication the facility followed up on the reported incident of alleged sexual abuse by notifying the Administrator or designee, conducted an investigation, or implemented resident interventions to reduce reoccurrences of inappropriate touching.
The facility failed to implement their policy of reporting and investigating an allegation of sexual abuse.
On May 31, 2017, Resident A's record was reviewed. Resident A was admitted to the facility on April 15, 2016, with diagnoses that included Alzheimer's disease (an irreversible, progressive brain disorder that destroys memory and thinking), major depression, and unspecified dementia (disorder of the brain affecting behaviors).
A nursing note dated March 27, 2017, at 11:07 p.m., indicated, "Resident in hallway around 3 pm when a CNA (Certified Nursing Assistant) walked by and noticed that the resident was fondling with another male resident inappropriately..."
A care plan initiated December 27, 2016, indicated Resident A exhibited prior behaviors of inappropriate touching. The focus statement indicated, "The resident has a behavior problem, has a tendency to touch staff and other resident's inappropriately..." The care plan was not updated to reflect the incident of March 27, 2017. There was no measurable goal or new interventions documented in an attempt to prevent future reoccurrences of Resident A inappropriately touching other residents.
On March 31, 2017, at 11 a.m., the Administrator was asked for the facility investigation of the March 27, 2017, incident. At 12:16 p.m., the Administrator stated March 27, 2017, was his first day at the facility and he did not recall the incident.
On May 31, 2017, the facility's policy and procedure titled, "Abuse Policy," with a release date of July 2015, was reviewed. The policy indicated:
"POLICY...The facility will prohibit abuse...for all residents through the following...Investigation of incidents and allegations...Reporting of incidents, investigations...
PROCESS...1. The Administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse...
5.1 Anyone who witnesses an incident of suspected abuse...is to report the suspected abuse immediately.
5.1.1 The notified supervisor will report the suspected abuse immediately (not to exceed 24 hours) to the Administrator or designee and other officials in accordance with state law... Upon receiving information concerning a reported suspected or alleged abuse...the Administrator or designee will perform the following...
6.7 Initiate an investigation within 24 hours of an allegation of abuse...
6.8 The investigation will be thoroughly documented on the facility's investigation form and log..."
An unannounced visit was made to the facility on June 22, 2017. During an interview with the Administrator at 2:05 p.m., the Administrator stated he checked with the former Director of Nursing who said she remembered it being reported and an SBAR (a type of assessment conducted for changes in resident condition) was completed. The Administrator further stated he did not have any data or an incident report that he could find. He stated, "I cannot find anything," and verified the facility policy had not been followed.
On June 22, 2017, at 3 p.m., Resident A's SBAR communication form and progress note dated March 27, 2017, at 10:18 p.m., was reviewed. The SBAR did not have any documentation indicating the Administrator or designee was notified of the incident or if an investigation was started.
It was determined the facility failed to implement their policy for reporting and investigating an alleged incident of sexual abuse by Resident A toward a male peer.
The above violation either jointly, separately, or in any combination had a direct or immediate relation to resident health, safety, or security. |
| 960002211 |
R & C QUALITY CARE |
960013276 |
B |
8-Nov-17 |
1V1H11 |
4816 |
Health and Safety Code 1265.5 (f)
Upon the employment of any person specified in subdivision (a), and prior to any contact with clients or residents, the facility shall ensure that electronic fingerprint images are submitted to the Department of Justice for the purposes of obtaining a criminal record check.
On January 25, 2017, at 6:11 a.m., an unannounced annual recertification survey was conducted.
The facility failed to ensure electronic fingerprints (live scan) for 3 direct care staff (DCS), Staff A, B, and C were submitted to the Department of Justice prior to providing care for 6 clients residing in the facility. This failure placed all 6 clients at risk for potential harm.
The clinical record for Clients 1, 2, 3, 4, 5, and 6 were reviewed on January 27, 2017, indicating the clients had diagnoses that included mild (developmentally functions at one half to two thirds of chronological age, is slow in all areas, but can acquire practical and vocational skills) and profound (cognitive ability that was markedly below average level - less than one fifth of chronological age) intellectual disabilities and depended on staff for all activities of daily living.
During a review of the facility's employee file for Staff A, on January 25, 2017, indicated Staff A was hired on August 17, 2016 for the position of direct care staff (DCS). There was no documentation to support a new Live Scan application had been submitted to the California Department of Public Health (CDPH) Department of Justice (DOJ) Criminal Background Clearance Unit for the purpose of securing a criminal clearance.
A review of Staff B's employee file indicated the Staff B was hired on December 29, 2016. There was no documentation to support a Live Scan application had been submitted to the CDPH DOJ Criminal Background Clearance Unit for the purpose of securing a criminal record clearance.
A review of Staff C's employee file indicated the Staff C was hired on August 9, 2016. There was no documentation to support a Live Scan application had been submitted to the CDPH DOJ Criminal Background Clearance Unit for the purpose of securing a criminal record clearance.
On January 25, 2017, at 11:55 a.m., the Interactive Voice Response Unit (IVRU) was called for verification of Live Scan Application submission. The IVRU recording indicated there was no record on file for Staffs A, B, and C.
During an interview with the Administrator (ADM), on January 27, 2017, at 11:06 a.m., she stated she delegated the responsibility of obtaining criminal background clearances to the Facility Manager (FM). The ADM stated the staff should have had a live scan completed before entering the facility. The ADM stated the facility should not have accepted prior documentation of criminal clearance through the California Department of Social Services for Staff A, B, and C.
During an interview with the ADM assistant, on January 27, 2017, at 11:17 a.m., he stated Staff A works at two different facility's and works Monday through Thursday from 5:00 p.m. to 8:00 p.m. and Saturday and Sunday from 7:00 a.m. to 3:00 p.m. Staff B works Monday to Wednesday from 3:00 p.m. to 7:00 p.m., Friday from 3:00 p.m. to 7:00 p.m., and Saturday from 7:00 a.m. to 3:00 p.m. Staff C works Sunday from 3:00 p.m. to 7:00 p.m., Monday from 7:00 a.m. to 11:00 a.m., Tuesday/Saturday from 11:00 p.m. to 7:00 a.m., and Thursday/Friday from 7:00 a.m. to 11:00 a.m.
The facility?s policy and procedure titled "Criminal Background" undated, indicated all employees are required to have clearance of criminal background check by the following: Live Scan Process. There was no supporting documentation to explain the live scan process.
The facility policy and procedure titled ?Prevention of Abuse, Neglect, and Mistreatment? undated, indicated in the Screening section as follows: In order to prohibit the employment of individuals with a conviction, all DCS are either cleared through the Department of Health Services centralized fingerprint data base and telephone directory, or they submit a set of fingerprints to the facility Administrator or designee prior to working directly with individuals receiving services. In the case when fingerprints are directly submitted to the Administrator, the submitted fingerprints are forwarded to the Department of Health Services and processed by the Department of Justice.
The facility failed to ensure electronic fingerprints (live scan) for 3 direct care staff (DCS), Staff A, B, and C, were submitted to the Department of Justice prior to providing care for 6 clients residing in the facility. This failure placed all 6 clients at risk for potential harm.
The above violation had a direct relationship to the safety and security of the clients residing in the facility. |
| 960002211 |
R & C QUALITY CARE |
960013598 |
A |
8-Nov-17 |
736L11 |
12103 |
WELFARE AND INSTITUTIONS CODE
SECTION 4500-4519.7
4502. Persons with developmental disabilities have the same legal
rights and responsibilities guaranteed all other individuals by the
United States Constitution and laws and the Constitution and laws of
the State of California. No otherwise qualified person by reason of
having a developmental disability shall be excluded from
participation in, be denied the benefits of, or be subjected to
discrimination under any program or activity, which receives public
funds.
(b) It is the intent of the Legislature that persons with
developmental disabilities shall have rights including, but not
limited to, the following:
(8) A right to be free from harm, including unnecessary physical
restraint, or isolation, excessive medication, abuse or neglect.
On 7/28/17, at 6:40 p.m., an unannounced visit was made to the facility to conduct a complaint investigation regarding Client 1 sustaining bilateral first and second-degree burns, from scalding hot water to her buttocks during a shower, on 7/22/17.
The facility's staff failed to:
1. Monitor the water temperature as Staff A showered Client 1 and the water became scalding hot.
2. Provide appropriate first aid to the burn. Staff A applied petroleum jelly to the burned area. According to The Red Cross, as soon as possible, Staff A should have cooled the burn with large amounts of cool running water and not apply any kind of ointment on a severe burn.
These failures to prevent scalding hot water in the facility and to provide appropriate first aid resulted in Client 1 suffering discomfort, pain and skin damage.
During a review of the clinical record for Client 1, on 7/28/17, the face sheet indicated the client was admitted to the facility with diagnoses that included profound intellectual disability (cognitive ability that is markedly below average level, incapable of self-care) and spastic quadriplegia cerebral palsy (most severe form of cerebral palsy in which ones ability to coordinate body movements of all four limbs and the trunk are affected including problems with muscles that control the mouth and tongue, and difficulty in speaking).
A review of the psychologist's Psychological Assessment, dated 5/31/17, indicated Client 1's overall adaptive capability rating was in the low range of 0-13, the client scored a one in the following areas: requires constant monitoring in safety awareness, requires complete assistance in bathing and hygiene, severely restricted receptive capability and non-verbal language capability.
During an interview and illustration, on 7/28/17, at 6:50 p.m., Staff A stated on 7/22/17, as he was preparing Client 1 for her shower and saw she had a large bowel movement. Staff A placed Client 1 on the shower chair in the bathroom, turned on the shower water and it was cool. Staff A stated he washed her front, illustrating in between the front of her legs and perineal area, while the client sat in the shower chair facing the shower faucet. Staff A stated and illustrated, afterwards the water had gotten warmer, he placed the showerhead under the shower chair and pointed the showerhead water stream upwards, spraying the water on to the client's buttocks for approximately 1 minute to clean her buttocks. Staff A stated while the water was still spraying onto Client 1's buttocks, without making a sound; she began to raise her legs upwards, from the floor, extended into a horizontal position. Staff A stated that was when he thought the water was too hot and he removed the water stream showerhead from under the client, sprayed his gloved left hand and quickly turned off the water.
Further interview with Staff A, on 7/28/17, at 7:46 p.m., he stated after he took Client 1 out of the shower, he dried her off and put her in the bed right away. Staff A stated her buttocks was red, and he realized Client 1 was burned. He applied petroleum jelly to the burned skin and Client 1?s skin "came off." He then telephoned the registered nurse (RN)/Licensee #2 and Staff B, who was assisting another client in the facility. Staff A stated, Staff B went to see Client 1 and saw her skin had come off. Staff A stated, no one told him to apply the petroleum jelly. When asked if he had taken first aid training, he responded, he took first aid training the previous year, at his other place of employment. He was asked if applying petroleum jelly was his usual post shower routine and he said, no, he applied it specifically for the burn. He further stated he informed the RN/Licensee #2, Licensee #1 and Staff B of his actions and no one instructed him that applying petroleum jelly was improper first aid. Staff A stated he has not received first aid instruction since the incident occurred. Staff A stated he received an in-service on how to properly shower a client after the incident. Staff A provided a handwritten declaration of the events.
According to http://www.redcross.org/images/MEDIA_CustomProductCatalog/m55540601_FA-CPR-AED-Part-Manual.pdf, for a heat thermal burn, as soon as possible, cool the burn with large amounts of cool running water. Do not use any kind of ointment on a severe burn.
During an interview with the licensed vocational nurse (LVN), on 7/28/17, at 8:40 p.m., she stated Staff D telephoned her Sunday (7/23/17) and informed her Client 1 had been burned. The LVN stated she saw Client 1's burn area for the first time on Wednesday (7/26/17) when she assisted staff with cleaning Client 1. The LVN stated as of this morning they are applying Supra (Suprathel, one time application wound and burn dressing acts like a second skin and accelerates wound healing, per http://www.polymedics.de/us/products/suprathel/) to the burn area. The LVN stated Client 1's African American skin was now white where she had been burned. The LVN was then asked about first aid care of a burn, she stated she did not recall first aid care of a burn. The LVN stated she would not apply petroleum jelly to a burn and if she was burned, her first instinct would be to run cool water over the burn. She stated they had an in-service about checking the shower water temperature during client showers, but did not have a first aid in-service. The LVN stated she had not seen a burn care plan for the client. The LVN further stated she had worked Wednesday, Thursday and Friday, 7 a.m. - 12 p.m. She stated she was aware the physician ordered dressing changes.
During an interview with the RN, on 8/4/17, at 9:58 a.m., she stated Staff A should have waited for her instead of applying Vaseline to the burn. She stated Staff A did not receive first aid training at the facility. The RN was asked to provide the facility's first aid policy. The policy was not provided.
A review of the emergency room discharge summary, dated 7/22/17 indicated Client 1 was assessed for first and second-degree burns. The discharge instructions indicated medicine may be given to decrease pain. Follow up with your healthcare provider or burn specialist as directed and to prevent second-degree burns, keep your water heater settings low to medium.
During an observation of Client 1, in her bedroom, on 8/4/17, at 8:10 a.m., the client's burn went from the bottom of her buttock's check (where her leg meets the buttocks) to the top of the buttocks (the top of the groove between the buttocks), approximately 7-8 inches [15-20 centimeters (cm)] long and approximately 5 inches (13 cm) wide. The lower parts of the burned skin was pink and red, and the top portion of the burn brown and red. The skin around the burn was dark brown. The client's natural skin tone was a light to medium brown.
During an interview with the house manager, on 8/4/17, at 8:18 a.m., she stated Client 1 has had to remain home in bed since she had been burned. She stated when Client 1 is placed into her wheelchair she moves excessively in pain from the burn.
During an interview with Licensee 1, on 8/4/17, at 9:09 a.m., he stated Staff A, probably turned the water nozzle on and put the hot water directly on Client 1 without checking the water temperature, because water does not go from "cold to hot in the blink of an eye."
During an observation of the hot water heater, and an interview with Owner 1 and the house manager, on 7/28/17, at 7:23 p.m., the hot water heater was located in a separate room with the thermostat dial (temperature adjusting/regulating knob) blocked by the washing machine it was facing next to it. Owner 1 was asked how was he able to regulate the water temperature since he could not visualize the thermostat dial. He stated the hot water heater did not have numbers to set the thermostat dial and they regulated the temperature based on the house manager's water temperature readings with a thermometer. The hot water heater instructions were requested and Owner 1 stated he did not have the instructions for the hot water heater that was purchased in 1998. Pictures were taken of the water heater's attached label that indicated, "water temperature over 125 degrees F can cause severe burns instantly or death from scalds. Temperature limiting valves are available, see manual. Any thermostat setting of water heater thermostat which is above the mark (there are no numbers on the hot water heater only marks) that approximates 120 F may cause accidental scalding, severe burns, or other injuries." A photo was taken of the hot water thermostat dial in order to read the settings since the washing machine blocked both view and easy access to the thermostat dial. The photo revealed the dial was set passed the word HOT/triangle (to the right of Hot/ greater than 120 F [see below]) in between the letter A on the dial.
According to http://c.kenmore.com/assets/own/33616e.pdf, Kenmore Power Miser 6 Gas Water Heater Owner's manual indicated the thermostat dial readings. The triangle/HOT is a setting of 120 F which produces 2nd and 3rd degree burns in more than 5 minutes. The letter A represents 130 F which produces 2nd and 3rd degree burns in 30 seconds.
A review of the RN's notes dated 7/22/17, indicated at 4 p.m., "DCS reported that (the) client sustained burn(s) on (her) bilateral buttock(s) due to high water temperature when cleaning client... by using water coming (from) shower head. DCS claimed that (the) water was ok at the start, and then suddenly (the) water temperature got too hot." The RN's notes continued at 4:20 p.m. and indicated "RN assessed (the) client('s)... affected body part assessed, measured injured area L (left) buttock 3 1/2 x 5 cm, Rt (right) 8 cm x 5 cm. Covered affected area with 4x4 sponge. Given Tylenol for pain. Sent to ? ER (emergency room) for assessment and treatment..."
During a review of the employee files on 8/4/17, Staff A's employee file indicated he had standard first aid training while working at another facility. There was no supportive documentation that the facility provided Staff A with First Aid training/in-service.
According to http://www.mayoclinic.org/diseases-conditions/burns/multimedia/second-degree-burn/img-20006132, a second-degree burn is serious as it involves layers of skin, that is extremely red, sore, swollen, blistered and severely painful requiring pain relievers.
The facility's staff failed to:
1. Monitor the water temperature as Staff A showered Client 1 and the water became scalding hot.
2. Provide appropriate first aid to the burn. Staff A applied petroleum jelly to the burned area. According to The Red Cross, as soon as possible, Staff A should have cooled the burn with large amounts of cool running water and not apply any kind of ointment on a severe burn.
These failures to prevent scalding hot water in the facility and to provide appropriate first aid resulted in Client 1 suffering discomfort, pain and skin damage.
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. |
| 630014893 |
Royal Haven, LLC |
980013613 |
B |
14-Nov-17 |
IN3Y11 |
7824 |
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.
72523 Patient Care Policies and Procedures
(a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.
72527 Patients? Rights
(a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public on request. Patients shall have the right:
(9) To be free for mental and physical abuse.
On 9/20/17 at 2:45 p.m., an unannounced visit was made to the facility to investigate a facility reported incident regarding allegation of physical abuse of Patient A by Licensed Vocational Nurse 1 (LVN 1).
Based on observation, record review, and interview, the facility failed to ensure Patient A was treated with dignity and respect and was not subjected to physical abuse; the facility failed to implement its policies and procedures on Abuse Prevention, Abuse Reporting, and Verification of Education and Work Background, including:
1. Failure to ensure Patient A was not physically abused and was treated with dignity and respect by LVN 1 slapping her twice in the face.
2. Failure to implement the facility?s policy and procedures on Abuse
Reporting by Certified Nursing Assistant 1 (CNA 1) waiting four days to report after witnessing LVN 1 slapping Patient A.
3. Failure to implement the facility?s policy and procedure on Verification of Education and Work Background by not verifying LVN 1?s work experiences for employment.
As a result, Patient A had sustained facial redness and was fearful of LVN 1.
On 9/20/17 at 2:30 p.m., Patient A was observed resting in bed. During a concurrent interview, in the presence of CNA 2, Patient A complained a staff member slapped her twice on the right side of her face. Patient A stated she was very scared, and she wanted to call police. She further stated she was tired and did not want to answer any more questions as she wanted to forget the incident.
A review of the Resident Data Sheet dated 7/22/15 indicated Patient A was admitted to the facility on 7/22/15 with diagnoses including traumatic brain injury (when a bump, blow, or other head injury causes damage to the brain).
A review of the Care Plan dated 7/20/17 indicated Patient A required total assistance with toilet use, personal hygiene, dressing, and needed limited assistance with bed mobility. The Care Plan interventions included assisting Patient A with activities of daily living (ADL), allowing Patient A to be involved in her care, and if resisting with care, trying again later or have another staff to approach Patient A. The Care Plan dated 7/20/17 indicated Patient A had care concerns due to her periods of agitation, paranoia (intense feelings of anxious or fearful feelings), disruptive behavior, resisting care, and striking out at staff. The Care Plan interventions included resuming care after Patient A had calmed down or attempt other safe behavioral intervention to prevent injury to Patient A.
A review of the Nursing Flow Sheets from 9/11/17 to 9/17/17 indicated Patient A was alert and oriented to person, place, and time. Patient A was able to make her needs known.
A review of the facility?s Investigation Report of the abuse allegation dated 9/18/17 and signed by the Director of Nursing (DON) indicated on 9/14/17 at 10:30 p.m., CNA 1 and LVN 1 were changing Patient A?s incontinent brief and bed linens, when Patient A became very agitated. Patient A was screaming, yelling, kicking, pinching, cussing, and resisting care. Patient A then spit on CNA 1?s face. As LVN 1 held down Patient A?s hands so that CNA 1 could wipe the spit from her face, LVN 1 slapped Patient A?s face twice. According to CNA 1, she was shocked to witness the slapping and observed Patient A?s face turned red. CNA 1 told LVN 1 they needed to leave the room and leave Patient A alone. When LVN 1 was interviewed by the DON on 9/17/17, he denied the slapping Patient A. When CNA 1 was interviewed on the same day, she stated she was sticking to her story and she, ?Saw what she saw.? LVN 1 was suspended on 9/17/17.
On 9/20/17 at 4 p.m., during an interview, the DON stated the incident occurred on 9/14/17 but CNA 1 did not report the incident until 9/18/17 when an investigation was started. The DON stated CNA 1 reported to LVN 2 she witnessed LVN 1 physically abusing Patient A on 9/14/17.
On 9/24/17 at 11 a.m., during an interview, CNA 1 stated she should have immediately notify a supervisor of the incident and not waited four days later to report LVN 1?s abuse towards Patient A.
A review of a text message sent to the DON dated 9/17/17, provided by the DON, indicated when LVN 1 held Patient A?s hands down, LVN 1 slapped her face two times really hard and Patient A yelled, ?You don?t hit me, you don?t hit me! You are not allowed to hit me and I am going to call the cops.?
According to a written statement of CNA 1 dated 9/19/17 at 5:30 p.m., CNA 1 stated that on the night of the incident, she was planning to tell the administrative nurse but LVN 1 stayed late in the facility, and CNA 1 was very uncomfortable, and in shock.
On 10/27/17 at 10 a.m., during an interview, LVN 1 stated he did not slap Patient A.
A review of LVN 1?s personnel file indicated LVN 1 was hired by the facility on 12/4/16. A review of the Verification and Reference Check for LVN 1 indicated there was no evidence the facility conducted a verification of references for employment as indicated in the facility?s policy. On 10/27/17 at 10:45 a.m., during an interview, the DON confirmed there was no verification of references.
The facility?s policy and procedures dated June 2014 on Verification of Education and Work Background indicated the facility will verify all work experiences on applicants for employment.
The facility?s policy and procedures dated June 2011 on Abuse Prevention, indicated each patient has the right to be free from physical abuse.
The facility?s policy and procedures dated April 2014 on Abuse Reporting indicated the employee would immediately notify their supervisor, contact the local law enforcement agency, file a written report, and a copy of the written report would be sent to the administrator. The supervisor or the administrator would be assigned to conduct an investigation and take the appropriate steps to prevent future incidents of abuse.
The facility failed to ensure Patient A was treated with dignity and respect and was not subjected to physical abuse; the facility failed to implement its policies and procedures on Abuse Prevention, Abuse Reporting, and Verification of Education and Work Background, including:
1. Failure to ensure Patient A was not physically abused and was treated with dignity and respect by LVN 1 slapping her twice in the face.
2. Failure to implement the facility?s policy and procedures on Abuse
Reporting by CNA 1 waiting four days to report witnessing LVN 1 slapping Patient A.
3. Failure to implement the facility?s policy and procedures on Verification of Education and Work Background by not verifying LVN 1?s work experiences for employment.
As a result, Patient A had sustained facial redness and was fearful of LVN 1.
The above violation had a direct or immediate relationship to the health, safety, or security of Patient A. |
| 630013665 |
Ridgecrest Regional Transitional Care and Rehabilitation Unit |
120013652 |
B |
30-Nov-17 |
QHV411 |
2397 |
Health and Safety Code 1418.91(a):
(a) A long-term health care facility shall report all allegations of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
(b) A failure to comply with the requirements of this section shall be a class "B" violation.
On 10/26/17 at 11:20 AM, an unannounced visit was conducted at the facility to investigate a facility reported event regarding the possible neglect of Resident 1.
Resident 1 was 89 year old male, with diagnosis of status post right hip fracture, generalized muscle weakness, chronic obstructive pulmonary disease (COPD-type of obstructive lung disease characterized by long-term breathing problems and poor airflow).
On October 9, 17, Resident 1 reported to staff that Certified Nursing Assistant 1 (CNA 1) took away his urinal and call light. Resident 1 stated CNA 1 was angry with him and made him feel like a burden.
The Department determined the facility failed to report an allegation of abuse and neglect to the Department within 24 hours of Resident 1 notifying the facility staff.
During a record review of "Intake Information", the Facility Reported Incident of resident neglect was reported to the California Department of Public Health on 10/20/17 at 3:34 PM. This report was 11 days after the incident.
During interview with the Assistant Director of Nursing, (ADON), on 10/26/17, at 1:10 PM, the ADON verified knowledge of Resident 1's report of neglect. The ADON stated "I should have reported it [the allegation of resident neglect]."
During an on interview with the Director of Nursing (DON) and the Administrator, on 10/26/17, at 2:35PM, the DON verified an allegation of neglect was reported to him by Licensed Vocation Nurse 1 (LVN 1) on 10/9/17. The DON stated he did not report the incident at that time to the Administrator or proper authorities (the Ombudsman or to the Department). The DON stated, "My fault. It slipped my mind". The Administrator verified the findings.
The facility policy and procedure titled, "Abuse Investigation and Reporting" dated, 12/2016, indicated "All reports of resident abuse, neglect...shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported." |
| 250000021 |
RIVERSIDE BEHAVIORAL HEALTHCARE CENTER |
250013468 |
B |
7-Sep-17 |
IE9J11 |
8960 |
F 226 483.13 (c) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
On May 9, 2017, at 8:15 a.m., Patient A reported to staff that she had been raped by Patient B the previous evening, May 8, 2017, at approximately 8 p.m. The patient stated she felt afraid since the rape occurred.
After Patient A reported her alleged rape by Patient B, the facility failed to:
1. Provide follow-up care for the Patient A after the alleged rape; and
2. Ensure Patient B was placed on one to one Behavior Precaution (BP) monitoring (one staff member with the patient at all times to ensure the safety of other patients), as outlined in the policy and procedure, in order to ensure Patient A's safety.
These facility failures increased the potential for serious psychological and physical harm or injury for patients in the facility.
On May 10, 2017, an unannounced visit was made to investigate this entity reported incident.
On May 10, 2017, a facility policy and procedure titled, "Reporting Suspected Cases and/or Incidents of Rape," dated August 2012, was reviewed. The policy indicated:
"...3. The following action must be taken in cases of suspected / actual rape:
...a. Assess the patient for possible injuries...
...b. Provide medical treatment, as indicated, to prevent further deterioration in the patient's health. Provide the patient with emotional support..."
1. On May 10, 2017, a review of facility documentation dated May 9, 2017, at 1:40 p.m., indicated Patient A went to staff on May 9, 2017, at 8:15 a.m., and reported she had been raped by Patient B the previous evening, May 8, 2017, at approximately 8 p.m.
On May 20, 2017, a record review was conducted for Patient A. The patient was admitted to the facility on April 27, 2017, from an acute psychiatric facility with diagnoses including schizoaffective disorder, bipolar Type (chronic mental health condition which can include severe symptoms of hallucinations, delusions, mood disorders, and depression). Patient A's history and physical dated May 2, 2017, was reviewed and indicated the patient had the capacity to understand and make decisions.
On May 10, 2017, at 12:15 p.m., an interview was conducted with Patient A. During the interview she stated that, on May 8, 2017, at approximately 8 p.m., (Patient B's name) came into her room and told her he wanted her to be his girlfriend. She stated (Patient B's name) took off his pants, climbed on top of her, placed his penis in her vagina, and had sex with her. In addition, she stated there were two male patients standing at the doorway watching, but she was too afraid to say anything. Patient A stated, when Patient B was done he got off of her, wiped himself off, got dressed and left the room. Patient A stated, "I was really scared when he forced me to have sex with him."
On May 10, 2017, an observation of Patient A's room was conducted. The room was observed to have two beds, with Patient A's bed located closest to the entry door for the room.
A review of the nurse's notes from May 9, 2017, at 8:15 a.m., to May 10, 2017, at 12:15 p.m., was conducted. The following was noted:
May 9, 2017, 7 a.m.-3 p.m. (day shift): There were no nursing notes for this shift. One program note at 1:40 p.m., indicated the patient reported to staff at 8:15 a.m., that she was raped the previous evening. Patient A stated she did not feel safe at the building. There was no documented nursing assessment after the rape allegation or indication of what type of interventions, if any, were provided for Patient A.
May 9, 2017, 3 p.m.-11 p.m. (afternoon shift): A nurse's note at 10:15 p.m., indicated Patient B was on a one to one after she alleged she was raped by a male peer. The patient denied pain related to the alleged rape. There was no documented assessment or indication of what type of interventions beside the one to one, were provided for Patient A.
During a review of nursing notes on May 10, 2017, at 12:15 p.m., there were no other nurse's notes or documentation of a nursing assessment for Patient A in the 28 hour time frame after Patient A made the allegation of rape against Patient B.
On May 10, 2017, at 11:45 a.m., during an interview with the Director of Nursing (DON), she stated the nurse's notes and interventions for the alleged rape were documented on the SBAR (Situation Background Assessment Recommendation) form (a form the facility uses to document an incident). A review of the SBAR form was conducted. The SBAR form did not include documentation indicating the facility completed a physical assessment and/ or assessed the patient's need for emotional support after the alleged rape.
In addition, the DON stated the police officer who came to the facility after the alleged rape was reported, stated he did not think the alleged rape ever happened. The DON stated, based on the police officer's opinion, the facility staff agreed that the alleged rape never occurred. The DON stated, if staff thought the alleged rape had actually occurred, they would have done more comprehensive documentation of Patient A's assessments and documented any immediate interventions put into place for Patient A by the psychiatric team.
On May 10, 2017, at 12:30 p.m., during an interview with the DON, she stated the facility should not have based their investigation on the police officer's opinion on the allegation of rape. The DON stated the facility should have followed the policy and procedure and completed the documentation and appropriate interventions for Patient A after the patient reported the alleged rape.
2. On May 10, 2017, a facility policy and procedure titled, "Abuse Procedure," dated April 2017, was reviewed. The policy indicated:
"Client to Client Abuse Procedure:
...Whenever client to client abuse is alleged, witnessed, reported or suspected to have occurred staff will implement the following steps to assure client safety:
...1. Separate clients immediately. Aggressor to be placed on a 1:1 Behavioral Precautions monitoring."
On May 10, 2017, a record review was completed for Patient B. The patient was admitted to the facility on November 22, 2016, from an acute psychiatric facility with diagnoses including Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). A history and physical, dated December 7, 2016, indicated Patient B had the capacity to understand and make decisions.
On May 10, 2017, at 11:45 a.m., during an interview with the Director of Nursing (DON), the DON stated Patient B was already on an every 15 (Q-15) minute watch (patient checked on by staff every 15 minutes) for aggressive behaviors when the alleged rape occurred. She stated, since Patient B was already on a Q-15 minute watch, they just continued the Q-15 minute watch after the allegation of rape.
On May 10, 2017, the facility documentation log of the May 8, 2017, Q-15 minute monitoring for Patient B during the time of the alleged rape was reviewed. The Q-15 minute monitoring log indicated Patient B was in his room from 7 - 9 p.m., and was asleep from 7:30 - 8 p.m.
During an interview conducted with Patient B on May 10, 2017, at 1:10 p.m., Patient B stated that he was in (Patient A's name) room on May 8, 2017, between 7:30 - 8 p.m., (during the time Patient A stated she was raped). Patient B stated they had "consensual sex" that evening and "she never told me no and I did not force myself on her." Patient B added that no one was watching them from the doorway.
On May 10, 2017, at 1:30 p.m., during an interview conducted with the DON, she reviewed the Q-15 minute documentation for May 8, 2017. The DON confirmed the facility staff documented Patient B was in his room asleep between 7:30 - 8 p.m., when Patient B stated he was in Patient A's room having sex with her. The DON stated the Q-15 minute documentation was not accurate and did not reflect Patient B's location on May 8, 2017, from 7:30- 8 p.m.
On May 10, 2017, during a review of the facility's investigation and follow-up of the alleged rape, there was no indication the facility placed Patient B on one to one monitoring Behavioral Precautions (BP), per the facility abuse policy and procedure, immediately after the accusation was reported to staff.
On May 10, 2017, at 6:25 p.m., during an interview with the DON, she stated Patient B should have been placed on a one to one monitoring BP watch, per the facility policy and procedure, immediately after Patient A reported the alleged rape.
This facility failure placed all facility patients at risk for abuse and at increased risk for physical and emotional harm.
The above violations either jointly, separately, or in any combination had a direct or immediate relation to patient health, safety, or security. |
| 950000007 |
Ramona Nursing & Rehabilitation Center |
940013482 |
A |
8-Sep-17 |
YG6X11 |
12778 |
CFR 483.24 Quality of life
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
CFR 483.25 Quality of care
Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices.
CFR 483.21(b) Comprehensive Care Plans
(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at ?483.10(c)(2) and ?483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under ?483.24, ?483.25 or ?483.40; and
(ii) Any services that would otherwise be required under ?483.24, ?483.25 or ?483.40 but are not provided due to the resident's exercise of rights under ?483.10, including the right to refuse treatment under ?483.10(c)(6).
On 5/26/17, at 7:40 a.m., an unannounced visit was conducted to the facility to investigate an entity reported incident regarding injury of unknown origin.
Based on interview, record review, and review of facility video, the facility failed to transfer (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position) Resident 1 using two or more staff in accordance with the comprehensive assessment and plan of care.
On 5/23/17, at 11:41 a.m., Certified Nursing Assistant 2 (CNA 2) transferred Resident 1 from a shower chair to a wheelchair by herself. After the shower, CNA 1 transferred Resident 1 from the wheelchair to the bed by herself. On 5/23/17, at 4 p.m., CNA 3 observed Resident 1 with swelling, discoloration, and pain on the right hip.
This failure resulted in Resident 1 being transferred to the hospital on 5/24/17, and was diagnosed to have right hip and right knee fractures (broken bones).
A review of Resident 1's record titled, "Record of Admission," indicated Resident 1 was admitted to the facility on 12/29/15, with diagnoses that included muscle weakness.
A review of Resident 1's record titled, "Minimum Data Set (MDS, a resident assessment and care screening tool), dated 4/2/17, indicated Resident 1 was severely impaired with cognitive skills (mental abilities or processes) for daily decision- making. The MDS indicated Resident 1 required extensive assistance (staff provided weight bearing support) with activities of daily living including transfer requiring two or more persons to provide physical assistance with transfer. The MDS indicated Resident 1's balance was not steady.
A review of Resident 1's record titled, "Fall Risk Assessment (a tool used to assess residents for risk for falls)," dated 4/17/17, indicated Resident 1 was identified high risk for falls.
A review of Resident 1's care plan, untitled, dated 4/17/17, indicated Resident 1 required assistance with transfers. The interventions included for two staff members to provide manual assistance (performed by staff without the use of a machine) with transfers.
A review of Resident 1's record titled, "Physical Therapy (PT) Evaluation and Plan of Treatment," dated 5/18/17, indicated under Functional Assessment that Resident 1 was unable to transfer and was unable to stand. Resident 1needed a Hoyer lift (a machine used to lift and transfer a resident) and two-person transfer assist for safety.
A review of Resident 1's record titled, "Situation, Background, Assessment, Request (SBAR - a tool used to facilitate prompt and appropriate communication among physicians and nurses) and Progress Note," dated 5/23/17, at 4:18 p.m., indicated CNA 3 reported to Licensed Vocational Nurse 1 (LVN 1) that Resident 1 was complaining of pain when turned. The SBAR indicated upon assessment, Resident 1's right hip was observed with swelling and slight discoloration. The SBAR indicated Resident 1's right leg was observed shorter than the left leg. The SBAR indicated the physician was called and gave an order for x- ray of the right hip, femur (thigh bone), and knee.
A review of Resident 1's record titled, "Radiology Interpretation," dated 5/23/17, indicated,
- Right knee:
Acute (sudden onset) or subacute onset (rapid change) fracture (broken bone) of the lateral (the outer side) tibial (one of two bones in the leg below the knee) plateau (near the knee joint) with mild depression (downward movement) and comminution (crushed).
- Right hip with pelvis:
Mildly displaced (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) right femoral (thigh bone) intertrochanteric (upper part of the thigh bone, near the hip) fracture.
A review of Resident 1's untitled nursing notes, dated 5/24/17, at 1:14 a.m., indicated Resident 1's primary physician (Physician 1) was made aware of Resident 1's x-ray result on 5/23/17, at 11:45 p.m., with order to transfer Resident 1 to the hospital in the morning. The nursing notes indicated Physician 1 stated that there was no point of transferring the resident to the hospital now because the resident will not be seen by an Orthopedic doctor (a physician devoted to the diagnosis, treatment, prevention and rehabilitation of injuries, disorders and diseases of the musculoskeletal [muscles and bones] system) tonight. The nursing notes indicated, "Resident is sleeping at this time, no facial grimacing noted."
A review of Resident 1's untitled nursing notes," dated 5/24/17, at 10:05 a.m., indicated Resident 1 was transferred to the hospital on 5/24/17, at 9:45 a.m., by paramedics (trained personnel to give emergency medical care).
A review of Resident 1's hospital record titled, "Emergency Room Routine," dated 5/24/17, at 10:33 a.m., indicated Resident 1 arrived in the emergency room by paramedics. The Physical Examination indicated that Resident 1?s right leg was short and externally rotated (rotation of a limb or part of a limb away from the midline of the body) and Resident 1 had some mild to moderate edema (swelling) of his right knee.
A review of Resident 1's hospital record titled, "Consultation," dated 5/24/17, indicated that the reason for consult was due to right hip and right knee fractures. The Consultation indicated, "Detailed discussion of the patient's current situation and options was made today with the patient's next of kin, and who has apparent power of attorney (appointed to make decisions on the resident's behalf), patient's son, and details of his condition were provided. After appropriate questions were asked, determination was made by the patient's son to proceed with non-operative treatment in view of the minimal displacement of the fractures, and patient's long-time non-ambulatory (not able to walk) status. As such, the patient will be treated conservatively (no surgery) utilizing analgesics (medications used to relieve pain) and medical care.
During an interview on 5/26/17, at 8:27 a.m., CNA 1 stated Resident 1 was transferred from the bed to a shower chair with two CNAs on 5/23/17, at 11:30 a.m. CNA 1 stated CNA 2 took Resident 1 to the shower room. CNA 1 stated she went for her lunch break and when she came back from lunch, Resident 1 was on a wheelchair. CNA 1 stated she did not know who helped CNA 2 transfer Resident 1 from the shower chair to the wheelchair. CNA 1 stated she transferred Resident 1 back to bed at 1:30 p.m. by herself. CNA 1 stated she did not ask another CNA to help her transfer Resident 1 back to bed because Resident 1 was sometimes able to help. When asked about Resident 1's plan of care with transfers, CNA 1 stated Resident 1 required two-person assistance with transfers.
During an interview on 5/26/17, at 8:45 a.m., CNA 2 stated on 5/23/17, she used the standing lift machine to transfer Resident 1 from the shower chair to the wheelchair. CNA 2 stated that was the first time she used the standing lift machine for Resident 1. CNA 2 stated CNA 1 helped her during the process of transferring Resident 1 from the shower chair to the wheelchair. CNA 2 stated Resident 1 required two-person assistance with transfers.
During an interview on 5/26/17, at 9:40 a.m., Physical Therapist 1 (PT 1) stated Resident 1 required two staff assistance with transfers due to Resident 1's cognitive decline and inability to balance while standing. PT 1 stated she provided Resident 1 treatment exercises on 5/23/17, between 7 a.m. to 8 a.m. and Resident 1 tolerated the exercises without pain or discomfort. PT 1 stated Resident 1 could be transferred using the standing lift machine but needed two staff to perform the transfer.
During an interview on 5/26/17, at 12:20 p.m., Resident 2, Resident 1's roommate, stated he was always in the room and he did not observe Resident 1 fall.
During an interview on 5/26/17, at 1:15 p.m., CNA 3 stated while she was rendering care to Resident 1 on 5/23/17, at 4 p.m., Resident 1 was observed with swelling to his right hip with slight discoloration. CNA 3 stated Resident 1 was complaining of minimal pain when turned. CNA 3 stated she reported to LVN 1 immediately. CNA 3 stated LVN 1 came and assessed Resident 1.
During an interview on 5/26/17, at 1:45 p.m., the Director of Nursing (DON) stated Resident 1 required two-person assistance with transfers whether by manual assist, meaning two CNAs to lift or by using a lift machine. The DON stated a lift to stand machine needs two staff, one to operate the machine and the other staff to stand by the resident. The DON stated that during the facility investigation of the incident, she heard from staff that sometimes Resident 1 was transferred by one staff. The DON stated during her conversation with Resident 1's family member, there will be no surgery recommended for Resident 1 due to Resident 1's age and heart condition.
On 5/26/17, at 2:45 p.m., during a review of the facility video camera taken on 5/23/17, CNA 2 took Resident 1 to the shower room in a shower chair. CNA 1 brought Resident 1's wheelchair and parked the wheelchair outside the shower room with Resident 1's clothes on the seat of the wheel chair then left. CNA 1 did not enter the shower room. CNA 2 took the wheelchair inside the shower room and at 11:41 a.m., CNA 2 and Resident 1, who was on the wheelchair, came out from the shower room.
During an interview on 8/2/17, at 9:15 a.m., the DON stated CNA 2 was terminated on 6/2/17. The DON stated CNA 2 was afraid to admit that she transferred Resident 1 alone inside the shower room because she knew that two-person assist was needed during Resident 1's transfer.
During an interview on 8/9/17, at 3:10 p.m., the Orthopedic Physician (Physician 2) stated Resident 1 had double fractures, one in the right hip and one in the right knee. Physician 2 stated based on his professional experience, these kinds of fractures could not result from osteopenia (Resident 1's diagnosis) or from moving and bumping on hard surface or object. Physician 2 stated the kind of fractures that Resident 1 had was sustained from a fall from a height. Physician 2 stated it would take a fall to get these kinds of injuries or fractures.
A review of the facility's policy and procedures titled, Lifting Machine, Using a Portable," dated 4/2007 indicated, "The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, two (2) nursing assistants will be required to perform the procedure."
Therefore, the facility failed to transfer Resident 1 using two or more staff in accordance with the comprehensive assessment and plan of care.
On 5/23/17, at 11:41 a.m., CNA 2 transferred Resident 1 from a shower chair to a wheelchair by herself. After the shower, CNA 1 transferred Resident 1 from the wheelchair to the bed by herself. On 5/23/17, at 4 p.m., CNA 3 observed Resident 1 with swelling, discoloration, and pain on the right hip.
This failure resulted in Resident 1 being transferred to the hospital on 5/24/17, and was diagnosed to have right hip and right knee fractures.
The above violations jointly, separately, or in combination presented either an imminent danger that death or serious physical harm would result to Resident 1. |
| 950000007 |
Ramona Nursing & Rehabilitation Center |
940013550 |
A |
19-Oct-17 |
CA2R11 |
16665 |
42 CFR ?483.10(g)(14) Notification of Changes
(i) A facility must immediately inform the resident; consult with the resident?s physician; and notify, consistent with his or her authority, the resident representative(s) when there is?
(A)An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B)A significant change in the resident?s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C)A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D)A decision to transfer or discharge the resident from the facility as specified in ?483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in ?483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is?
(A)A change in room or roommate assignment as specified in ?483.10(e)(6);
Or
A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s).
42 CFR 483.12(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95.
?483.95(c) Abuse, neglect, and exploitation.
In addition to the freedom from abuse, neglect, and exploitation requirements in ? 483.12, facilities must also provide training to their staff that at a minimum educates staff on?
?483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at ? 483.12.
?483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property
?483.95(c)(3) Dementia management and resident abuse prevention.
42 CFR ? 483.24 Quality of life
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
? 483.25 Quality of care
Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
?483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.
On 6/22/17 at 10:45 a.m., an unannounced complaint visit was conducted regarding Resident 1 being choked by Resident 2 on 6/9/17 and Resident 1 had sustained a neck fracture.
Based on interview and record review, the facility failed to implement its policy and procedure regarding resident to resident altercation and change of condition notification by failing to:
1. Report to Resident 1?s attending physician that Resident 2 choked Resident 1.
Resident 2 choked Resident 1 on 6/9/17 inside their shared room and the licensed vocational nurses (LVN 1 and 2) and the registered nurse (RN 1) did not inform Resident 1's attending physician that Resident 1 was a victim of a choking incident so that the attending physician could give orders to examine Resident 1 for any injuries.
This deficient practice resulted in delayed intervention for Resident 1. On 6/14/17, five days after the choking incident, Resident 1 was transferred to a general acute care hospital (GACH) due to his neck tilted to the right. Resident 1 had a broken neck and he became paralyzed (loss of the ability to move one or more muscles). Resident 1 had to undergo two surgical procedures, a tracheostomy (tube inserted through a hole in the neck) to assist in his breathing and a gastrostomy (a surgical opening through the abdomen into the stomach used for feeding and medications) as a route to receive nutrition.
This deficient practice also resulted in Resident 1 to experience fear for his life and safety.
A review of Resident 2's Admission Record indicated the resident was a 65-year-old male, who was admitted to the facility on 3/12/10, with diagnoses that included paranoia (irrational fear), anxiety (feelings of worry, anxiety, or fear that can affect daily life) and dementia (loss of brain function that affects memory, thinking, language, judgment, and behavior).
A review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 3/19/17, indicated the resident had a clear speech, and was usually able to express ideas and wants. The MDS indicated Resident 2 needed extensive assistance (resident involved in activity; staff providing weight bearing support) with bed mobility, transferring, and walking. The resident used a walker or wheelchair as mobility devices and had no limitations in range of motion (the range through which a joint can be moved) in his upper and lower extremities.
A review of Resident 1's Admission Record indicated the resident was a 79-year-old male, who admitted to the facility on 5/22/17, with the admitting diagnoses of pneumonia (inflammation of the lungs due to an infection), chronic obstructive pulmonary disease (COPD, a lung disease that block airflow and make it difficult to breathe), and muscle weakness.
A review of Resident 1's MDS, dated 2/22/17, indicated the resident had a clear speech, and was able to express ideas and wants. The MDS indicated Resident 1 was unable to walk and he needed extensive assistance with bed mobility, transferring, and locomotion on the unit (how the resident moves between locations in his room and adjacent corridor on the same floor).
A review of Resident 1 Situation, Background, Assessment, Recommendation (SBAR, a framework for communication between members of the health care team about a resident's condition) and Progress note, dated 6/10/17 at 10:26 a.m., indicated Resident 1 stated he was taking a nap when his roommate, Resident 2, came to the side of his bed and started yelling that he (Resident 1) was in his (Resident 2's) bed. Resident 1 stated Resident 2 stood up and tried to choke him and pull him out of the bed. Resident 1 appeared to be frightened. Body checked performed with no apparent injuries notes. No discolorations or changes to the skin noted. The SBAR and progress note indicated Resident 1's primary physician (MD 1) was notified on 6/9/17 at 2 p.m., regarding the resident-to-resident altercation.
A review of Resident 1's Resident Transfer Record, dated 6/14/17, indicated Resident 1 was transferred to GACH due to change in mobility level to the upper extremity, stiff neck with tilting to the right.
A review of Resident 1's GACH record titled, "Consultation," dated 6/15/17, indicated, Resident 1 had a worsening neck pain, difficulty in walking, weakness in his upper extremities, and breathing issues. Resident 1 was admitted to the emergency room last night. CT scan (computed tomography, a type of x-ray that produces images of the specific part of the body) of the cervical (neck) spine showed that Resident 1 has a C4-C5 (fourth and fifth bone of the neck) anterolisthese (forward displacement of the spine) with C5 fracture (broken fifth bone of the neck) and severe cord compression (a condition that puts pressure on the spinal cord). Resident 1 was currently intubated (a tube is inserted through the mouth and into the airway to assist with breathing) in the ICU (intensive care unit, a special hospital unit with specialized equipment and specially trained personnel to care for seriously ill patients) after coding (a medical emergency, especially in a hospital, when a patient's heart stops beating or his or her lungs stop functioning) last night.
A review of Resident 1's GACH record titled "Operative Report," dated 6/21/17, indicated the operation performed were a tracheostomy, upper gastrointestinal endoscopy (a procedure that allows your doctor to look at the inside lining of your esophagus, your stomach, and the first part of your small intestine) and percutaneous endoscopic gastrostomy (PEG, a procedure in which a tube is passed into the stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate).
During a telephone interview with FM 1, on 6/21/17 at 1:50 p.m., she stated that Resident 1 was currently in the intensive care unit (ICU).
During an interview with licensed vocational nurse (LVN 1), on 6/22/17 at 2:20 p.m., she stated Resident 1 informed her that Resident 2 tried to choke him and pull down the light that was over his head. LVN 1 stated she tried to calm Resident 1 down. LVN 1 stated Resident 1 said to her, "Get me out of this room, he is trying to kill me."
During a telephone interview with Resident 1's primary physician (MD 1), on 6/30/17 at 12 p.m., he stated he remembered getting a call from the facility that Resident 1 was having weakness and the facility wanting to transfer him to GACH (on 6/14/17). MD 1 stated the emergency room doctor called him from the GACH and updated him what was going on with Resident 1 regarding the fracture of the neck. MD 1 stated, "And after that I didn't hear anything back."
During the interview, MD 1 stated he went to the hospital and spoke to FM 1, who told him that Resident 1 was choked by another resident. MD 1 stated, "I did not know any of this. I went to the facility the next day and spoke to the administrator and I asked him what happened because I was not aware of the choking. The administrator was surprised. I mean, what could he say? If the facility called me and told me my resident was choked by another resident, I would have ordered tests or transferred him to the hospital. The facility calls me all the time regarding other issues falls, medication, change of conditions, but this is something very important more than a medical issue. Something like this happens and we need to act upon it. These kinds of things do not happen that often. I never got a call regarding (Resident 1) being choked by another resident."
During an interview with Licensed Vocational Nurse (LVN) 2, on 6/30/17 at 2 p.m., she stated, "Yes, I remember the incident. I was on lunch break when it happened. The certified nurse assistant (CNA) came and got me." LVN 2 stated that when she went to see Resident 1, he was in the room in the bed and Resident 2 was not in the room. LVN 2 stated that Resident 1 looked very scared, and Resident 1 informed her that Resident 2 tried to choke him. LVN 2 stated she left a message on MD 1's pager and Registered Nurse 1 (RN) 1 possibly notified Resident 1's daughter. LVN 2 stated, on 9/15/17 at 3:27 p.m., that she did not contact MD 1 again. LVN 2 stated that she told the incoming nurse during the nurse-to-nurse report and that they should follow up.
During an interview, on 6/30/17 at 2:10 p.m., RN 1 stated, after reviewing the Situation, Background, Assessment, Recommendation (SBAR) and Progress note, dated 6/10/17 at 10:26 a.m., that she spoke to FM 1 after the incident. RN 1 stated FM 1 knew about the incident right away because Resident 1 called her on his cell phone. RN 1 stated she did not call MD 1 to notify him about the resident-to-resident altercation. RN 1 stated the SBAR and progress note indicated MD 1 was notified about the resident-to-resident altercation on 6/9/17 at 2 p.m.
During an interview, on 6/30/17 at 2:30 p.m., the director of nursing (DON) stated the SBAR looked like LVN 2 talked to MD 1 and notified MD 1 about the altercation. The DON stated LVN 2 should have documented that she left a message so that the next shift could have followed up with MD 1.
During an interview with the DON, on 9/15/17 at 1:55 p.m., she stated that they separated both residents (Resident 1 and Resident 2) immediately as soon as Resident 1 informed the facility staff member regarding being choked by Resident 2. When asked if the physician must be notified, the DON stated, during an interview at 4:02 p.m., "Yes we have to. There should be a follow up phone call to physician." When asked how many times they have to try to notify the physician that a change of condition had occurred with a resident, the DON stated that they must try until the physician could answer. When asked if a resident being choked was considered a change in condition, DON stated it is considered a change in condition.
During an interview with FM 1, on 9/18/17 at 11:05 a.m., she stated that Resident 1's neck was fine prior to the incident (on 6/9/17) and that Resident 1 was even able to feed himself and move around. FM 1 stated that Resident 1 was now paralyzed and since he was not able to move, Resident 1 had developed pressure sores (damaged skin caused by staying in one position for too long). While crying on the phone, FM 1 stated, "They were not doing what they were supposed to do. They did not protect him. They did not follow procedure. If they sent him sooner to the hospital, maybe he would not be paralyzed. I visited him every day. If I had not been there that Wednesday, he would have died because I noticed what happened to him and when he was in the emergency room, his heart and breathing stopped. He should have gone straight to the hospital on that day." FM 1 stated that Resident 1 told her, "Honey they are letting me die."
A review of the undated facility's policy and procedure titled "Resident to Resident Altercations," indicated all altercations, including those that may represent resident to resident abuse, shall be investigated and reported to the Nursing Supervisor, Director of Nurses and to the Administrator. If two residents are involved in an altercation, staff will: notify each resident representative (sponsor) and Attending Physician of the incident.
A record review of the facility's policy and procedure titled, "Change of Condition Notification," dated 4/1/15 indicated the facility will promptly inform the resident, consult with the resident's Attending Physician, and notify the resident's; legal representative or an interested family member, of known, when the resident endures a significant change in their condition caused by, but not limited to: an accident. A significant change in the resident's physical, mental or psychosocial status; and or a significant change in treatment.
The facility failed to implement its policy and procedure regarding resident to resident altercation and change of condition notification by failing to:
1. Report to Resident 1?s attending physician that Resident 2 choked Resident 1.
Resident 2 choked Resident 1 on 6/9/17 inside their shared room and the licensed vocational nurses (LVN 1 and 2) and the registered nurse (RN 1) did not inform Resident 1's attending physician that Resident 1 was a victim of a choking incident so that the attending physician could give orders to examine Resident 1 for any injuries.
This deficient practice resulted in delayed intervention for Resident 1. On 6/14/17, five days after the choking incident, Resident 1 was transferred to a general acute care hospital (GACH) due to his neck tilted to the right. Resident 1 had a broken neck and he became paralyzed (loss of the ability to move one or more muscles). Resident 1 had to undergo two surgical procedures, a tracheostomy (tube inserted through a hole in the neck) to assist in his breathing and a gastrostomy (a surgical opening through the abdomen into the stomach used for feeding and medications) as a route to receive nutrition.
This deficient practice also resulted in Resident 1 to experience fear for his life and safety.
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. |