| 020000068 |
St John Kronstadt Convalescent Center |
020009676 |
B |
12-Dec-12 |
VIFI11 |
5496 |
483.12(b)(1)&(2) NOTICE OF BED-HOLD POLICY BEFORE/UPON TRANSFERBefore 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 violated the above regulation by failing to: 1. Provide Resident 1 and a family member or legal representative written information about their bed-hold policy.2. Follow facility policy and allow Resident 1 to return to the facility after hospitalization. Review of the medical record on 9/20/12 showed that the facility admitted Resident 1 on 8/18/12. She had diagnoses that included altered mental status, hypoglycemia, subarachnoid hematoma, head injury and acidosis.A "Care Conference IDT", (interdisciplinary team) dated 8/22/12, reflected that the facility held a care conference with Resident 1's daughter to discuss the following problems: refusal of therapy screening; refusing medications; refusing care; frequently calling out to staff. The facility told Resident 1's responsible party (RP) that Resident 1 needed a sitter, or to be placed in a, "Board and care/Home Care, that will be able to provide a more 1:1 care for the resident". RP did not agree with the facility. She told the staff to try a different approach. The IDT went on to discuss Resident 1's mental status, and behaviors of calling out in the night. RP and the IDT discussed the possibility of sending Resident 1 to a psychiatric facility for evaluation. The IDT decided to implement interventions that included: 1. Staff will continue to provide care, continue to offer meds and other nursing care. 2. SSD (Social Services Designee) and/or DON (Director of Nursing) will contact PCP (Primary Care Physician) to obtain an order for psychiatric consult to have resident evaluated. 3. SSD will provide 1-1 visits of conversational therapy and validating resident's feelings. The "Admission Nursing Assessment", dated 8/18/12, and a "Nursing Assessment", dated 8/23/12, showed that Resident 1 was very confused, disoriented; uncooperative, was refusing medications and most foods.On 8/24/12, following two falls out of her wheelchair, the physician ordered a 5150 (psychiatric evaluation) transfer to an acute care hospital for evaluation, stating she was trying to hurt herself.Resident 1 was admitted to an acute psychiatric facility on 8/25/12. Further review of the facility record showed that there was no documented evidence that the facility issued a written bed hold notice to Resident 1 and a family member at the time of transfer for hospitalization. The facility's policy for Health Record Content, page 20 reflected that, "The facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed-hold policy upon admission or within 24 hours of a transfer". In an interview, on 9/18/12, the hospital discharge planner (DP) stated that she called the facility on 8/30/12, to report that Resident 1 was stable, and ready to return to the facility. DP stated that the Acting Director of Nurses (ADON) told her that the facility could not take care of the resident, and they were refusing to take her back.Review of the hospital record, on 9/20/12, showed a Social Service Progress Note, dated 8/30/12. DP documented that she told ADON that it was the facility's responsibility to, "Take Resident 1 back, and find her another appropriate place, vs. dumping her here." The note reflected that ADON told DP that Resident 1 was dumped on them, and the facility refused to take her back. During an observation and interview at the acute psychiatric facility at 2:30 p.m., on 9/20/12, Resident 1 was sitting in a wheel chair and was alert and calm.During an interview on 11/16/12 at 9:20 a.m., RP stated she never received a notice of a bed hold on admission, or after the 5150 transfer from the facility. RP stated, "They didn't give me anything when she was admitted or when she went to the hospital. I first heard of a 7 day bed-hold at the hearing".Therefore, the facility failed to: 1. Inform the resident and a family member or legal representative in writing of the right to exercise a seven day bed hold upon transfer for hospitalization on 8/24/12. 2. Follow facility policy and readmit the resident to the facility when notified by the acute psychiatric facility that the resident was stable and would be appropriate for return to the facility. On 9/04/12, the acute psychiatric facility contacted the facility again and stated the resident was improving and would be appropriate for return to the facility. The facility refused to readmit Resident 1. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to the resident. |
| 020000068 |
St John Kronstadt Convalescent Center |
020009728 |
AA |
04-Feb-13 |
L8HA11 |
7840 |
F323 - The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to follow the aforementioned regulation when it failed to provide one (1) of three sampled residents, the therapeutic diet ordered by the physician to ensure that Resident 1 was not given a food that was unsafe to eat. Resident 1 had a history of choking on foods. Certified Nursing Assistant (CNA) 1 and Activities Assistant (AA) accompanied Residents 1, 2, and 3 to a baseball game. The facility failed to assure that CNA 1 and AA knew that Resident 1 was to have a mechanical soft (soft chopped, blended or ground food, mechanically altered to make it easier to chew and swallow) diet. During the ball game, the staff bought the three residents hot dogs for lunch. While Resident 1 was eating his hot dog on a bun, he began to choke. Facility and ball park staff attempted to clear the hot dog from Resident 1's airway. The resident lost consciousness was taken to a hospital, where he died. The failure to provide Resident 1 with his prescribed diet resulted in his choking incident and death.Findings: Review of the clinical record on 9/21/12 at 9:30 a.m., showed that Resident 1 was a 92 year old male, admitted to the facility on 1/26/12 with diagnoses including dysphagia, (difficulty swallowing) and muscle weakness.Record review on 9/21/12, of the Minimum data Set (MDS) dated 7/18/12, showed that Resident 1 required assistance in setting up his meals.The Physician Admission Orders, dated 1/25/12, included an order for a pureed, (blended to a smooth consistency) 2000 calorie, diabetic diet. A Physician order, dated 2/6/12 showed, "Change diet to NCS (no concentrated sweets) Puree thin liquids secondary to poor mastication (chewing) of food. A Physician order dated 2/10/12 changed the diet to Mechanical soft, ground meat with extra gravy, no crust on breads; thin liquids (NCS).The "Therapy Progress Documentation" form, dated 2/10/12 reflected that Resident 1 reported a choking incident that occurred on 2/9/12, while eating a sandwich with crust for dinner. The therapist documented that he, "Tolerated a small amount of his mechanical soft lunch tray today with lengthy mastication but no overt signs or symptoms of aspiration (accidental inhalation of food or liquids into bronchi or lungs) noted. Patient able to (I) detail his swallow precautions. Changing diet to Mechanical Soft, ground meat with thin liquid - No crust." A physician order, dated 3/13/12, reflected that Resident 1 could go out of the facility on outings with his responsible party, and on facility outings. Care plans dated 1/28/12, and 5/1/12 for, "Potential for Constipation", showed Resident 1 was identified with "Swallowing problems." Care Plans for "Nutritional Status" dated 2/9/12, and 5/21/12 reflected that Resident 1 had swallowing problems.Review of "Interdisciplinary Team Conference Notes" dated 5/1/12 included Physician's orders, Diagnosis, Care Plan, MDS/Assessments. The Summary portion of the Interdisciplinary Team Conference Notes, Dietary section indicated, "Resident is on mechanical soft NCS diet with ground meat."Physician's Orders for 7/1/2012 to 7/31/2012 continued the Mechanical soft, NCS, Ground Meat with extra gravy, no crust on breads, thin liquids diet, and directed staff to check Resident 1's tray for accuracy, each Saturday.A nurses note, dated 7/18/12, reflected that Resident 1 was excited about going to a ball game that day. The 7/18/12 nurses note for 4 p.m., reflected that the assistant activities director called the facility at 3:30 p.m., to report that Resident 1 was choking, and losing consciousness. An entry at 4:30 p.m., reflected that Resident 1 was admitted to the hospital. In an interview on 7/20/12, at 5 p.m., the Administrator stated that Resident 1 was in the hospital intensive care unit, on a ventilator (mechanical breathing machine). During an interview on 9/21/12, at 9:30 a.m., the Administrator stated that when residents went out on pass, no medical information was sent with them. He stated that the facility sent, "Contact info" with residents who went out of the facility for outings. The Administrator further stated, "We have taken measures so this won't happen again."In an interview on 9/21/12, at 13:30 p.m., the Director of Nursing stated that the staff should have been aware of Resident 1's current diet, but, "Obviously they did not, or they wouldn't have given him a hot dog." The DON also stated that the staff did not have any records with them on the outing, except, "Contact info." During an interview with AA, on 10/4/12 at 10 a.m., she stated she did not know if Resident 1 had a history of choking. When asked if she knew what type of diet Resident 1 was on at the time of the 7/18/12 choking incident, she stated that she did not know. When asked if she knew whether an uncut hot dog on a bun was allowed according to Resident 1's diet order, she stated she did not know. AA stated that she and CNA 1 tried the Heimlich maneuver, and a man tried, but nothing came out.During an interview with Certified Nursing Assistant (CNA) 1 on 10/4/12 at 10:30 a.m., she stated that she did not have information about the residents' diets, medications, or special precautions when she took Residents 1, 2, and 3 to the ball game. She stated she did not know if Resident 1 had a history of choking. When asked if she knew what type of diet Resident 1 was on at the time of the 7/18/12 choking incident, she stated that she did not know. When asked if she knew if eating an uncut hot dog on a bun was allowed according to Resident 1's diet order, she stated she did not know. In an interview with the DON (Director of Nurses), on 10/11/12, at 10 a.m., she stated that Resident 1's daughter called the facility to report that he died at the hospital on 7/28/12. DON stated that prior to Resident 1's choking incident, the facility did not have a policy or procedure for residents going out of the facility. She stated that the practice was to notify the responsible parties that their resident was going on an outing. The DON stated that, as a result of Resident 1's incident, the facility developed an information form, to be filled in when a resident goes on an outing. Review on 11/28/12, of the, Coroner Investigator's Report, dated 7/30/12 at 4:29 p.m., showed, "Preliminary Summary - Accidental death of a 92 year old male at San Leandro Hospital. On 7/18/12, the decedent choked on a hot dog at a baseball game. Paramedics responded, partially removed a food bolus and transported to the ER (Emergency Room). Additional food bolus was removed in the emergency (room) and he was transferred to the ICU. His condition deteriorated (anoxic brain injury due to asphyxia)(air way blocked) and death was pronounced.... Cause of Death, A- Anoxic (lack of oxygen) Brain Injury, B-Aspiration of Food Material."The coroner's Medical Summary reflected, "According to (The Hospital) medical records, (Resident 1) was admitted to the hospital for respiratory arrest secondary to food aspiration with an anoxic brain injury on July 18, 2012. He was at a baseball game when he started choking on a hot dog. A bolus was removed by paramedics, he was transported to the hospital, and more of the bolus was removed by doctors in the emergency room." The coroner's, "Description of the Death/Injury Scene" reflected, "The decedent died as an in-patient at San Leandro Hospital - ICU. The decedent choked on a hot dog at the Oakland Coliseum during a baseball game." Failure by facility staff to ensure that Resident 1's dietary restrictions were followed while on a facility outing resulted in an imminent danger of death or serious harm to the resident. |
| 020000630 |
Serra Residential Center - Crestwood House |
020010162 |
A |
27-Sep-13 |
1CW411 |
7905 |
483.480(b)(2)(iii) Food must be served in a form consistent with the developmental level of the client. 483.480 (d) (4) the facility must supervise and staff dining rooms adequately.The facility violated the aforementioned regulation by failing to assure that there was sufficient staff to implement Client 1's eating program to protect Client 1's safety on 4/13/13 during a movie matinee, where food was served. Client 1's eating program called for staff to chop her food into bite sized pieces, supervise her during every meal to encourage her to eat slowly, and chew thoroughly. The staff sat across the room from Client 1 and did not know that someone gave her a hotdog, did not notice that Client 1 ate the hot dog, was choking and required immediate first aid, including the Heimlich maneuver.Another client, who was sitting close to Client 1, told DCS 2 (direct care staff) that Client 1 fell to the floor. DCS 2 saw that Client 1 was lying on her stomach, gasping for air. DCS 1 and DCS 2 failed to promptly perform lifesaving measures such as first aide and the Heimlich maneuver. As a result, when emergency medical technicians arrived, they were unable to revive Client 1. Despite resuscitative efforts, Client 1 choked on the hot dog, and died. Record review, on 4/30/13, showed that Client 1 was an alert and verbal middle-aged woman who was admitted to the facility in 12/06. Client 1 required supervision from facility staff because she was unable to make safe decisions about her daily life. Client 1's physician's orders for 4/1/13 to 4/30/13 included an order that Client 1 was to have her food chopped into bite size pieces.During an interview with DCS 6 on 4/30/13, she stated that Client 1 choked on a hot dog about 13 years ago and that the staff needed to watch her closely when she was eating. Client 1 had a training plan, dated 4/28/13, for the staff to observe her while she ate every meal and encourage her to chew her food thoroughly.Review, on 5/15/13, of a report written by the Community Center's Program Director, dated 4/13/13, showed that DCS 1 and DCS 2 and five facility clients arrived at the center approximately 40 minutes late to attend a 10:30 a.m. movie with refreshments. When the facility staff and clients arrived, the activity center was dark, the movie was running at a loud volume, and snacks were served.During an interview with DCS 1 at 6:40 a.m., she stated that hot dogs, popcorn, chocolate chip cookies were served to all of the clients attending the movie.During an interview with DCS 5, on 5/24/13 at 4:45 p.m., she stated that she assisted Client 1, Client 2 and Client 3 to the chairs that were available, across the room, separated from where DSC 1 and DSC 2 sat with two other clients (4, 5) who were physically dependent on staff for all their needs.During an interview with DCS 1 on 4/30/13, she stated that DCS 1 and DCS 2 were responsible for Client 1, and that the seating arrangement was, "Not a good idea".DCS 2 stated that she did not see Client 1 eat anything on 4/13/13, during an interview on 5/14/13 at 6:30 p.m.During observations and interviews, on 5/15/13 at 11:30 a.m., Community Center staff demonstrated where Client 1 and facility staff were seated on 4/13/13, during the movie. A measurement with a tape measure showed that the facility staff were approximately 22 feet away from Client 1, and separated by two tables.During an interview with the facility's registered dietitian on 6/20/13, at 1:30 p.m., she stated that when clients eat in the dark, supervision is not possible, and that clients can become very distracted by loud sounds, such as the movie.On 4/30/13, review of the facility incident as reported by DCS 1 and DCS 2, dated 4/13/13, showed that after the staff and clients obtained their seats, DCS 1 started to feed Client 5, and she heard someone say that that a person had fallen.During an interview with DCS 2 on 5/17/13, at 6:30 p.m., she stated that Client 2 came to her and told her that Client 1, "Passed out". DCS 2 said that when she found Client 1, she was lying on her stomach. DCS 2 started yelling and calling out Client 1's name. The facility incident report dated 4/13/13 showed that at this point Client 1 was gasping for air and that she had a pulse.Review, on 5/15/13, of a report written by the Community Center's Program Director, dated 4/13/13, showed that the Program Director called 911. When she returned from making the call, the facility's care providers, "Were next to me by the front door, and not anywhere near where the client was." The Program Director also documented that, "The care providers were just standing around," and, "The client's care providers were across the room, and left her unattended, which baffled me." She also documented that she wondered if Client 1 choked on food, because her care providers were not watching her. The Program Director wrote that she asked one of the facility staff why Client 1 was not sitting with them. The staff person told the Program Director that they were supposed to have three staff members in attendance and they did not. During an interview with DCS 4, on 5/6/13, she stated that she saw Client 1 lying face down on the floor. DCS 4 stated that DCS 2 appeared panicked and was on the floor on her knees next to Client 1. DCS 4 said that she helped DCS 2 turn Client 1 on her back, "To stabilize her airway" and noted that Client 1's face was completely blue. It was then that the paramedic arrived.During an interview, on 6/5/13, at 11 a.m., with a paramedic who arrived at the Community Center, on 4/13/12 at 11:33 a.m., he stated that Client 1 had no breathing or pulse when he arrived. The paramedic stated that he did not think that the staff started the cardiopulmonary resuscitation, (CPR) or the Heimlich maneuver before he arrived, which would have been the practice for an individual who was choking. The paramedic stated that Client 1 choked on a piece of hot dog that was approximately the diameter of a golf ball in size.During an interview on 5/17/13 at 6:50 p.m., DCS 2 stated that the facility was short of staff on 4/13/13, and that she needed to provide care to Client 4. DCS 2 stated that if there were more staff available on 4/13/13, it would have been possible for the staff to assist all the clients, as normally there would be three staff accompanying the clients.During an interview with the QIDP (Qualified Intellectual Disabilities Professional) on 6/6/13 at 3:30 p.m., he said that he knew on Friday, 4/12/13 that a direct care staff that provided one-on-one care for Client 4 would not come to work on 4/13/13, and that he was unable to schedule another staff person to come to work that day. The QIDP stated that he decided not to cancel the outing, because the ratio of five clients to two caregivers was close to the usual ratio of six clients to three staff, although Client 4 would not receive one-to-one care.During an interview with Client 1's primary physician on 6/24/13 at 12:25 p.m., she stated that the facility needed to have staff who knew what actions to take during emergencies such as choking, and that this was important to recognize so this type of incident would not occur again. A review of the "Coroner Investigative Report" dated 4/15/13, showed that Client 1 died on 4/13/13, of asphyxia, foreign body obstruction of the airway (bolus of food). Therefore the facility violated the regulations when: 1. The facility did not ensure that Client 1 received food, a hot dog, in a form that was safe for her to eat.2. The facility did not give Client 1 the supervision she required to make sure she chewed her food and ate at a safe pace. And the facility did not provide supervision to identify a swallowing difficulty and immediately respond when she began to choke.This presented imminent danger that death or serious harm would result, or serious physical harm would result. |
| 140000396 |
Shields Nursing Center |
020010274 |
B |
20-Nov-13 |
ZM9Z11 |
8362 |
THIS SECTION 1424 NOTICE - CITATION NUMBER 02-2352-0010274-S IS AMENDED TO INCLUDE THE REGULATION VERBIAGE CITED. ALL OTHER ITEMS OF THE CITATION REMAIN UNCHANGED AND EFFECTIVE. T22 DIV5 CH3 ART5-72527(a)(6) Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record.Patients have the right to be transferred or discharged only for medical reasons, to be given reasonable advance notice to ensure orderly discharge. Such actions shall be documented in the patients' health records. The facility violated the aforementioned regulation for three (4, 5 and 7) of seven sampled patients when it transferred patients 4, 5, and 7 involuntarily from Facility 1 to Facility 2, in another town away from their homes, social supports and familiar neighborhood, for the facility's convenience. The facility failed to give written notice of the impending transfers, with a chance to appeal. 1. Record review on 8/27/13 showed that Resident 4 was admitted to Facility 1 on 12/27/13 with diagnoses that included diabetes, heart disease, kidney disease and back pain. A physician's History and Physical, dated 1/1/0/13, showed that he had capacity to "understand and make decisions." A social service (SS) note showed, "...The goal is for resident to finish 100 days here at (Facility 1). Resident and daughter spoke by phone and have made decision for resident to be long term and transfer to (Facility 2). Another SS note, dated 4/17/13, showed, "Resident transferred from (Facility 1) to (Facility 2) due to resident now being long term care." During observation and interview on 8/27/13 at 2:30 p.m., Resident 4 was lying flat in bed in a dark room. Resident 4 stated that he came to Facility 2 from Facility 1. He stated, "I don't know why I was moved. I have no control over my movement. I only want my health back."During an interview on 8/29/13 at 3:50 p.m., RN 1 at Facility 1 stated, "With Residents 4 and 5, we had planned to discharge them home but they became long term or custodial. So they were transferred to Facility 2."During an interview on 8/27/13 at 2:40 p.m., RN 2 at Facility 2 stated, "At first, he (Resident 4) asked why he was moved. Now he seems to accept it." During a phone interview on 8/29/13 at 2:00 p.m., the Admissions Coordinator (AC) stated, "I don't know why he (Resident 4) was moved (from Facility 1 to Facility 2)." During an interview on 10/7/13 at 3:20 p.m., the assistant administrator (AADM) at Facility 1, stated, "We don't have a log of admits and transfers. The (AC) keeps track." Written tracking requested from AC and was sent to AADM. It showed, "Social worker spoke with patient; agreed to move." Review of a letter, dated 10/9/13, written by ADM, showed "I was informed that this (move by resident 4) was a resident-initiated request; however, the documentation does not support this. And no further documentation has been found at the facility."2. Review of the face sheet showed that Resident 5 was a 76 year old admitted to Facility 1 on 6/5/13. His diagnoses included blindness, diabetes, and heart disease. A physician's order showed that he had capacity to make his own decisions. During interview on 8/27/13 at 2:15 p.m., Resident 5 was in a darkened room at Facility 2, standing by his bed. He stated, "I understand Facility 1 is a short term and this is long term. I would have liked to stay at Facility 1. I stayed there as long as I could. I've lived in that town for 30 years and I'm active in the Lions Club there. Now a member comes and picks me up," to take me there. Review of the form from AC to the AADM at Facility on 10/7/13 showed, "Resident 5- Transferred directly from Facility 1 to Facility 2- Social worker spoke with patient and brother, they agreed to move." Review of a letter, dated 10/9/13, from the ADM, "There was a conversation with the resident (5) and a family member. This does not support my contention of a resident initiated request (to move). And no other documents have been located." During a phone interview on 10/17/13 at 12:45 p.m., Resident 5's brother stated, "They told us he was long term and would have to move to Facility 2 because they couldn't keep him there at Facility 1. He didn't have a choice about it. They said he had already been at Facility 1 too long. It bothered me because his primary doctor was in the town of Facility 1." 3. Review of the face sheet in the medical record showed that Resident 7 was admitted to Facility 1 on 5/1/13 with diagnoses that included a wound infection, diabetes, heart disease, seizure disorder and arthritis. The Minimum Data Set Assessment (MDS), dated 7/27/13, showed brief interview for Mental Status score of 15 out of 15. The Functional Status section showed that Resident 7 required limited assistance of one staff for activities of daily living. Her mobility devices were a wheelchair and a walker. There was a History and Physical, dated 4/16/13, that showed "Has capacity to understand and make decisions." There was a Discharge Plan Review, dated 7/22/13, that showed "SSD (social service designee) informed resident that last covered day is 8/01/13. SSD informed resident also placed call to daughter informing her. On 8/2/13 another SSD note showed "Resident discharged to Facility 2 with medications." During phone interview on 10/14/13 at 1:45 p.m., Resident 7 and her daughter stated that her Medicare ran out so she was moved because she was Medicaid only. The daughter stated, "She had no choice. They said private pay was the only way she could have stayed at Facility 1. It was a few hundred dollars per day."Review of a letter from the ADM, dated 10/9/13, "The notes are unclear who initiated the request for transfer. I do not have any other documentation to support a resident initiated request." Review of the facility's policy and procedure, Documentation of Transfers and Discharges, revised 3/11, showed: "Documentation from the Care Planning Team concerning all transfers or discharges must include, as a minimum, and as they may apply: a. The reason(s) for the transfer or discharge; b. That an appropriate notice was provided to the resident and/ or representative; c. That the resident and/ or representative participated in a pre- discharge orientation program;"This policy also required documentation by the physician: "...The basis for the transfer or discharge must be documented in the resident's clinical record by the resident's attending physician: a. The transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met at the facility." During interview on 8/20/13 at 10:30 a.m., RN 1 at Facility 2 stated, "Our facility is mostly long term. Ours is like a step-down for mostly custodial residents. We don't decide who transfers. The admissions coordinator (AC) sends us the referrals of admissions." During interview on 8/20/13 at 11:40 a.m., the administrator (ADM) stated, "For Facility 1, we have a specific number of short term and long term beds. That's our business model." During further interview on 8/29/13 at 2 p.m., the ADM stated, "None received a 30- day notice. The billing office only gives those for non- payment. No one (who was transferred) has physician documentation about this facility (Facility 1) not being able to meet their needs." During further phone interview on 10/8/13 at 3:30 p.m., ADM stated, "For voluntary transfers, we don't issue a written notice." During a phone interview on 9/25/13 at 11:00 a.m., the admissions coordinator stated, "I don't know anything about 30- day notices." These violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 140000136 |
San Miguel Villa |
020010295 |
B |
06-Dec-13 |
02CG11 |
6435 |
THIS CITATION IS AMENDED TO CORRECT THE INCIDENT/COMPLAINT NO. ALL OTHER ITEMS OF THE CITATION REMAIN UNCHANGED AND EFFECTIVE.The facility violated the aforementioned regulations when it failed to: 1. Continually assess Resident 1 for problems related to his indwelling catheter (tube inserted into the bladder to allow urine to flow out) such as signs and symptoms of blockage and infection. 2. Implement Resident 1's plan of care for the urinary catheter. 3. Follow the physician's orders to maintain the bladder catheter to be sure it flowed well. 4. Implement the facility's policy and procedure, "Catheter Care, Urinary." As a result of these deficient practices, Resident 1's indwelling catheter became clogged. He developed a bladder infection, then urosepsis (the spread of infection from the urinary tract to the entire blood stream). He became unresponsive, and had to be transported to an emergency department by ambulance. He was admitted, and required treatment for his infections with antibiotics. On 10/9/13, a review of the medical record showed Resident 1 was a 72 year old man admitted to the facility on 7/15/13. His diagnoses included multiple sclerosis, urinary tract infection, neurogenic bladder (bladder does not fill and empty properly), and failure to thrive. There was a resident assessment, dated 8/8/13, that showed that Resident 1 was totally dependent on staff for all activities of daily living. Nutrition was given through a gastrostomy tube (a tube surgically placed into the stomach). He had a memory problem and was moderately impaired in decision making. Nursing notes described him as, "Alert and responsive." Physician's orders, dated 7/31/13 and 8/8/13, directed the nurses to, "Irrigate Foley (bladder) catheter with 60 ml. (milliliters, 2 ounces) normal saline solution every shift daily." There was a physician's order dated 8/9/13, "Change Foley catheter as needed for plugging, clogging or leakage."Review of the facility's policy and procedure, titled "Catheter Care, Urinary," revised 10/10, directed, "1. Observe the resident's urine level for noticeable increases or decreases; 2. Maintain an accurate record of the resident's daily output." A care plan for "Indwelling Catheter," dated 10/15/13, listed the problem: "Resident is at risk for urinary infection and urethral discomfort due to the presence of urinary appliance. Goals: Maintain adequate urine output; Intervention: Observe for adequate urine output." Review of a nursing note, dated 9/14/13, showed, "Received him in bed sleeping comfortably. When the Certified Nurse Assistant (CNA) went to his room to feed him his breakfast, resident is not responding. Licensed nurse assessed the resident...and did sternal rub to arouse him but still not responding. Called the wife and according to her she will follow him in the ER (emergency room)."Review of the hospital emergency department record, dated 9/14/13, showed that Resident 1 was transferred to the hospital after he became unresponsive. The emergency department report, written by MD 3, reflected, "This 72 year- old male presents with departure from his baseline mental status. He has an obvious pyuria (pus in the urine) on exam clinically and confirmed by urinalysis ...His foley catheter appeared to be grossly draining pus. This was removed and exchanged. The patient also has a significant constipation and underwent manual disimpaction as well as enema." The diagnoses: Urosepsis, Encephalopathy (brain disorder) secondary to sepsis (infection of the blood) and dehydration." During interview on 10/9/13 at 11:35 a.m., LVN (licensed vocational nurse) 2 stated, "The catheter used to clog up really fast. I would irrigate it in the morning and it would be clogged in the afternoon. I've had to replace it before." During a phone interview on 10/15/13 at 10:05 a.m., the Director of Nursing (DON) stated, "There is no documentation that the Foley was ever taken out and replaced during August and September of 2013. I cannot find the intake and output (record) to show if it was draining before he was sent to the hospital."Review of the narrative Nursing Notes between 8/9/13 and 9/14/13, showed there was no documentation of the color, consistency or odor of the urine draining by gravity into the catheter bag.During a phone interview on 10/15/13 at 2:30 p.m., MD 3 stated, "The catheter was opaque, full of pus and not draining. It would not flow and had to be replaced. I'm sure that not draining made him at risk for an increasingly complicated course of treatment due to a more advanced infection. Irrigating would help release the pus and lets patients do better. The urinary tract infection is inevitable and it should have been irrigated to let the pus flow out. Being clogged contributed to the systemic infection. " During interview and concurrent record review on 10/16/13 at 11:00 a.m., LVN 2 stated "The Foley was never changed in August or September, 2013." During interview on 10/16/13 at 1:10 p.m., the facility physician (MD 4) stated that the staff never notified him of difficulty with the Foley catheter. Therefore, the facility failed to:1. Follow the physician's orders to maintain the flow of urine through the catheter with irrigations and to replace the catheter when it was clogged.2. Make sure there was a free flow of urine, as fluid intake and urinary output records were not found. 3. Notice a change in condition until the resident became unresponsive and needed to be sent to the hospital. In the emergency department, the catheter was clogged with pus and replaced. As a result of this failure, the catheter was clogged with sediment and contributed to urosepsis, the spread of infection from the urinary tract to the entire blood stream. According to the reference "Harrison's Principles of Internal Medicine," 18th edition, volume 2, page 2394, "Catheter-Associated UTI (urinary tract infection)- The formation of biofilm, a living layer of uropathogens (bacteria), on the urinary catheter is central to the pathogenesis (disease origin) of catheter associated UTI. The organisms in a biofilm are relatively resistant to killing by antibiotics and eradication of a catheter- associated biofilm is difficult without removal of the device itself. Catheters provide a conduit (path) for bacteria to enter the bladder." These violations had a direct and immediate relationship to patient health, safety or security of Resident 1. |
| 140000030 |
San Pablo Healthcare & Wellness Center |
020010744 |
B |
04-Jun-14 |
DLCF11 |
3512 |
72651. (d) Hot water controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by patients to attain a hot water temperature in compliance with Sections T17-210(e), Title 24, California Administrative Code. The facility failed to ensure that mandatory equipment for hot water heating was in place and functioning properly. On 5/20/14 a complaint from the California Office of Statewide Health Planning and Development (OSPHD) stated that the facility had been found out of compliance with Title 24 requirements for hot water heating. OSPHD had done an inspection of the facility on 11/9/2010 and found that: 1. There was no mixing valve on any of the three hot water heaters. 2. There was no alarm for overly hot water on the hot water heaters and no alarms at any of the nursing stations. 3. The hot water heaters had no seismic anchors. 4. The exhaust flues were not piped correctly. The OSPHD inspector stated that on 5/19/2014, during an inspection that the hot water heating conditions still existed. In the OSPHD inspector's opinion, all residents of the facility were at serious risk for hot water injury. During investigation of the complaint, on 5/20/14 from 2:15 p.m. to 3:55 p.m., each resident's room hot water temperature at the sink was measured. Multiple rooms had hot water at the residents' sinks that was in excess of 120 degrees Fahrenheit (temperature at which there is risk of scalding due to hot water per the surveyor guidelines, Federal State Operations Manual, F323).Bathrooms shared by rooms: 1 and 2 = 122.6 4 and 5 = 124.2 F 6 and 7 = 125.1 F 8 and 10 = 124.2 F 9 and 11 = 123.8 F Shower/Beauty Parlor = 120.6 F In an interview with the building Maintenance Supervisor (MS), on 5/20/14 at 4:34 p.m., when asked, he stated that there were no hot water alarms. MS stated that water temperature was controlled by thermostats on the three hot water heaters but he was not aware of the location of any mixing valves. MS stated that there were recirculating pumps, but no mixing valves. MS stated that he began working in the facility in 2010 and had not been given any manuals or plans for the hot water heating system. He did not know which water heaters supplied specific resident rooms. In concurrent observation, there was no visible pipe connected to a pressure relief valve. There were straps in place to secure the hot water heaters from tipping over during an earthquake. In an interview with the facility's Administrator, on 5/20/14 at 5:40 p.m., he stated that during an OSHPD survey, "A few years ago," that the water heaters were noted to be unpermitted. He stated that arrangements had been made with an outside contractor to address the issues with the water heaters, but that this was handled by the corporation (ownership of the facility). On 5/21/14, the Administrator forwarded via email a scanned copy of a receipt for plumbing work. According to the receipt the facility had paid for "commercial water heater repairs." Repairs included installation of a mixing valve and a recirculation pump with flush system. Therefore the facility violated the regulation when: The facility did not ensure the safety of residents from burns due to over heated water. The facility was in violation of T-24 codes for mandated hot water temperature control valves (mixing valves), hot water alarms, and exhaust flues. Violation of regulation had a direct or immediate relationship to the health, safety, or security of patients. |
| 140000080 |
Shields Richmond Nursing Center |
020010865 |
B |
17-Jul-14 |
KE2B11 |
4617 |
F323 483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility violated the aforementioned regulation, by failing to follow their care plan to have two staff participate when delivering care, to protect one (Resident 1) of six sampled residents from accidental injury.Resident 1 required two staff to assist with bed mobility, transfers and dressing and toilet use. On 4/26/14, Resident 2 (Resident 1's roommate) heard Resident 1 scream during care given by CNA 1. Resident 1 was noted to have purplish discoloration around the left eye, above her left eye immediately after receiving care. This failure resulted in ongoing discomfort for Resident 1. Review of the medical record on 5/5/14 showed that Resident 1 was admitted to the facility on 6/12/12 with diagnoses that included end stage renal failure with dialysis three times every week, diabetes, and dementia. The complete resident assessment, dated 3/4/14, showed that Resident 1 required the total assistance of two (CNA 1 and CNA 2) staff for bed mobility, transfers, dressing and toilet use. Care plans, revised and updated on 5/4/14, showed "impaired cognitive function", "communication problem," and "self- care deficit- required total assistance of two staff." An additional approach showed "keep side rails padded." The nursing progress notes, dated 4/26/14 at 2:43 p.m., showed, "Resident was reported to have swelling on her left forehead...at 1:20 p.m. (One of) her aides (CNA 2) asked if she knew what happened to resident. CNA 2 said that at the time she took care of the resident her forehead was not swollen nor was the side of her eye red. ..Cold compresses applied." Review of a nurse's note, dated 4/26/14 at 4:00 p.m., showed, "Patient has trauma to left eye. The left eye began to turn purple at the tear duct and expand 3/4 around the top and bottom of the eye. There was a knot above the eyebrow at the ending of the eyebrow." During interview on 5/5/14 at 9:10 a.m., the administrator (ADM) stated that Resident 1 was sent to the hospital due to respiratory problems on 4/28/14. ADM showed his investigative report, dated 4/28/14. It showed that RN 1 noted the injury when he went in the room to do a blood glucose reading before lunch. RN 1 reported to the charge nurse (LVN 2) and ADM was notified of the injury. "There were no eye witnesses but Resident 1's roommate (Resident 2) heard the resident cry out while CNA 1 was behind the curtain with the resident that morning. Spanish speaking staff tried to talk to Resident 1 on 4/28/14 about what happened but resident didn't say anything. Per report, she is usually not very verbal. This incident happened on the morning of 4/26/14, Saturday, during morning care. CNA (2) gave the morning care and denied knowing what happened or seeing the area. CNA (2) started out by herself, per her report, but then stated the treatment nurse came in and they did the treatment together. The treatment nurse (LVN 1) denies this and reports she did treatment without the CNA. Both deny injury to resident during care." During interview on 5/5/14 at 9:45 a.m., LVN 2, the charge nurse, stated, "The eyebrow was swollen and painful. I reported it to the physician and responsible party right away. When I saw it, I called CNA 2 and she said she didn't know about it. It wasn't seen by the RN or by me when I gave her medications earlier."During interview on 5/5/14 at 10:20 a.m., the DON stated, "The railings were padded after this incident. She must have hit the railing." During interview on 5/5/14 at 12:30 p.m., Resident 2, Resident 1's roommate, stated, "My roommate was behind the curtain with the CNA (2). I heard the resident yell out real loud, like a scream. The CNA didn't say anything in response. This was around 10 or 11:00 a.m." Resident 2 was ambulating in her room, was well groomed, alert, and conversant at the time of the interview. During a phone interview on 5/20/14 at 11:40 a.m., the Director of Nurses (DON) was asked why Resident 1 required two staff for turning in bed. DON stated, "She's heavy and weak. She's total care. Her grip was not strong, so another staff had to be on the other side to hold her there. Otherwise, she could bump herself." Therefore the facility failed to: Ensure that each resident received adequate supervision and assistance to prevent accidents.The above violation had a direct relationship to the health and safety of Resident 1. |
| 140000136 |
San Miguel Villa |
020011038 |
B |
02-Oct-14 |
ZMT411 |
5205 |
F323 483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility violated the aforementioned regulation when it failed to supervise Resident 1on 7/14/14, when she 1 wheeled herself out to the patio, when temperatures were over 100 degrees. She was discovered unresponsive, sent to the emergency room, diagnosed with heat stroke and second degree burns, and had an avoidable stay in the hospital. On 7/30/14, record review showed that Resident 1 was admitted to the facility on 11/1/13, with diagnoses that included dementia, epilepsy and pulmonary fibrosis (scarring of the lungs).The complete resident assessment, dated 5/14/14, showed that Resident 1 was moderately impaired in decision making, had short and long term memory problems, required supervision and cueing (direction) in activities of daily living, and required the extensive assistance of two staff for bed mobility and transfers. The care plan, dated 11/12/13, showed, "Difficulty with decision making, difficulty communicating needs." Review of nurses' notes, dated 7/14/14 at 3:18 p.m., showed, "Change in resident condition: Temperature-106 degrees, heart rate-66, respirations-20; Skin intact- hot; Resident was reported to have fainted, She was found at the outside patio slumped in her wheelchair by CNA 1 (certified nursing assistant) at 1:45 p.m. Supervisor attempted to arouse resident but resident was unresponsive. Resident was brought to her room. Emergency services were notified. Resident was stripped of her clothes. Skin was red and hot to touch. Cold compresses applied to her forehead, underneath her arms, on her back and down her legs in order to bring her temperature down..." Review of the hospital emergency room records, dated 7/14/14, showed, "The patient presents with acute (sudden) alteration in mental status. She was febrile (feverish) in the Emergency department. She was also having large amounts of diarrhea and cloudy urine. I suspect her primary trigger is acute heat stroke...given antibiotics and intravenous fluids. The patient did improve very significantly throughout her Emergency Department stay. Impression:1. Acute febrile illness. Heat stroke versus sepsis (a toxic condition due to spread of bacteria or their toxic products in the body); 2. Urinary tract infection; 3. Second degree burns to trunk and extremities; 4. Acute lactic acidosis (disruption of blood's acid/ base balance) with severe sepsis syndrome." The hospital physician's history and physical, dated 7/14/14, showed, "71 year old female...who has significant baseline dementia who is cared for by a conservator (a court- appointed decision- maker). Patient apparently has been in her usual state of health until today when she was last seen at 12:50 p.m. on a 100 + degree day. She was seen outside at 1:45 p.m. and was noted to be altered and temperature of 104 degrees. Patient started developing blistering on her back and cold compresses and clothing changed and she was brought here. Patient with risk of hypotension (low blood pressure), seizure risk, watch for liver injury, DIC (a lack of blood clotting syndrome), renal (kidney) injury, and arrhythmia (heart dysfunction)." During interview on 7/30/14 at 9:00 a.m., the Director of Nurses (DON) stated, "A CNA was taking another resident out to the patio and saw Resident 1 slumped over and tried to arouse her. He yelled for help and staff came to assess her. Her temperature was high so they took her clothes off and put wet towels all over her body. They called 911 and sent her out. After a few days in the hospital, she was transferred to another skilled nursing facility."During interview on 7/30/14 at 10:15 a.m., CNA 1 stated, "I found Resident 1 and I know her. She was slumped and drooling. I tried to arouse her and she didn't respond so I called for help. She wasn't in the shade. She likes being in the sun." During an interview on 7/30/14 at 11:15 a.m., Registered Nurse 1 (RN) stated, "Elderly are easily dehydrated. Heat stroke comes on fast. I was not aware she was out there until they brought her in. It was really hot that day." During an interview and concurrent record review on 7/30/14 at 11:45 a.m., the Director of Staff Development (DSD) stated, "I train the staff to make sure residents are hydrated. No one can go out unsupervised. If a staff takes a resident out to the patio, they have to monitor at least once every hour. DSD showed her attendance list and lesson plan for her training dated 6/22/14, addressing the elderly and hot weather. During phone interview on 8/5/14 at 3:30 p.m., Resident 1's conservator stated, "When I asked the facility staff what she was wearing that day, they told me she chose to wear a long sleeved shirt and long pants." Therefore, the facility failed to supervise Resident 1 to protect her from the harmful effects of the sun, resulting in hospitalization, heat stroke, and second degree burns. This failure had a direct or immediate relationship to the health, safety, or security of patients." |
| 140000136 |
San Miguel Villa |
020011061 |
B |
09-Oct-14 |
D9U211 |
12183 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility violated the aforementioned regulation when they failed to ensure, for Residents 1 and 2, their environment was free from possible accident hazards and that Residents 1 & 2 received adequate supervision in order to prevent avoidable accidents from occurring. Resident 1's bed was against a wall and an unpadded upper side rail was in use, despite the facility's knowledge of Resident 1 hitting his hands consistently and frequently against the wall and side rail. Resident 2 had multiple falls with injuries. Interventions were not modified nor implemented in order to reduce her risk of falls and serious injury.1. During a tour of the facility on 4/30/14 at 10:50 a.m., Resident 2 was observed sitting in a chair in the Dining & Activity Room. Resident 2 had a bluish-purple discoloration on her right upper cheek below her eye, a lighter blue-purple discoloration along her right temple and another yellowish-green discoloration on the upper right side of her forehead.In an interview on 4/30/14 at 11 a.m. with Resident 2 regarding the appearance of bruising on her face, Resident 2 stated, "I'm always falling". In a concurrent observation and interview on 4/30/14 at 11:10 a.m. Resident 2 walked to her room in a moderately slow, unsteady pace to show where she fell. The Certified Nursing Assistant (CNA 1) in the dining room stated, "She's a little unsteady, but she usually walks without assistance." Resident 2 wore non-skid socks on her feet without shoes. Resident 2's room was located at the furthest end of the hallway from the nursing station.During an interview and observation of Resident 2's room on 4/30/14 at 11:12 a.m., Resident 2's bed was in a semi-low position. Resident 2's bed had brakes on it. The brakes were not in use and Resident 2's bed moved easily when pushed against. Resident 2's wooden three drawer night stand table was immediately next to Resident 2's bed with the edges of the night stand table noted to be round. Across from Resident 2's bed was a night light fixture which was uncovered, inoperable and had wiring exposed. The floor was tiled. There was no cushioned mat to break a fall, nor did the bed have an alarm on it (to signal staff that Resident 2 had gotten out of bed).Resident 2 was asked to locate her shoes. Resident 2 went to her closet, her shoes weren't there.In an interview on 4/30/14 at 11:30 a.m., CNA 1 stated, "She had that bruise ever since I started working this unit at the beginning of April. I help her to the bathroom when she needs to go. Her shoes are in here, (indicated the bottom dresser drawer) because she just wears the non-skid socks." Review of the medical record on 4/30/14 showed Resident 2 was admitted to the facility on 7/1/13 and had diagnoses which included dementia. According to a Discharge Transfer Summary, and a Physician's Order, dated 3/20/13, from the transferring nursing facility, Resident 2 had a history of falls and right-sided weakness resulting from a stroke, wore glasses, was incontinent (no control over) bowel and bladder and needed a, "Tab alarm when in bed at all times and a placement check of the alarm was to occur every shift." Further review of physician's orders, dated 7/3/13, showed the staff were to observe Fall Precautions for Resident 2, and showed that upon admission, Resident 2 had right sided weakness, wore glasses and was incontinent of bowel and bladder functions.The "Fall Risk Evaluation," dated 7/1/13, showed Resident 2 was at high risk for falls. Resident 2 had falls on the following dates: 10/13/13, 10/21/13, 12/22/13, 1/23/14, and 3/20/14.The nursing care plan, dated 7/1/13, showed, "Staff would monitor for changes that would warrant increased supervision and assistance and notify the physician, and would supervise all ambulation."A care plan and post fall assessment, dated 10/13/13, showed after Resident 2 fell, she vomited six times (vomiting can be a sign of a concussion). Interventions included, "Neurology checks for changes in level of consciousness (assessment for signs of a head injury: pupil size and reaction to light, nausea, change in level of consciousness), give fluids as tolerated, meds as ordered, give a clear liquid diet and notify the physician and responsible party."A nursing care plan dated on 10/21/13 entitled, "After fall with head injury/side of face", showed staff would, "Apply ice to face swelling, pain meds, safety checks and neuro checks." A nursing care plan dated on 12/22/13 entitled, "Witnessed fall", showed staff would, "Monitor for pain, monitor for further injury, have Resident 2 wear comfortable shoes with laces properly tied."A "Post Fall Assessment," dated 12/22/13, showed Resident 2 tripped on her, "Untied shoe laces" at 3:00 p.m. The nursing care plan, dated 1/23/14, entitled, "Unwitnessed fall", showed staff would, "Notify the physician and responsible party, monitor Resident 2's walk, do neuro checks for three days, and monitor for pain." Review of the Post Fall Assessment dated on 1/24/14 showed that Resident 2 had a "Witnessed fall", at 10:45 p.m., in her bedroom and that she was, "Found sitting on the floor next to her bed facing in the direction of the window", and there were, "No apparent injuries and neuro checks were initiated for 72 hours." A nursing care plan dated on 1/25/14 entitled, "Nausea and vomiting" showed staff would notify the physician, responsible party, and staff, monitor vital signs every shift, and monitor for episodes of vomiting." The nursing care plan dated on 3/20/14 entitled, "Unwitnessed fall and head injury", showed staff would do neuro checks for 72 hours, monitor for signs of pain, assist with ambulation, apply ice to bump on right forehead and treat as ordered." A Post Fall assessment dated 3/20/14 showed that Resident 2 fell at 3:30 a.m. in her bedroom and sustained a cut to the right side of her forehead from the handle on her bedside dresser as evidenced by the bottom handle of her dresser being bent."Care Plan Conference Summaries," dated 1/9/14 and 4/3/14 showed no mention of Resident 2's fall patterns. In an interview on 4/30/14 at 2:00 p.m., Licensed Vocational Nurse (LVN) 1 stated, "She told you that she always falls? That's true. She falls just about every night during the night shift. She gets out of bed, getting up on her own, mostly between 2 a.m. and 4 a.m. The last time that she fell she was found on the floor with the night stand turned over onto the floor along with her.She hit the corner of the night stand and she needed to have a wound closed on her forehead." In an interview on 4/30/14 at 4:00 p.m., the Director of Nursing (DON), stated the facility's fall program consisted of "Hallway Monitors at Station 3 and 4 who are designated each day, who are walking up and down the hall and wear orange and red vests for identification proposes." "The Hallway Monitors are to be in constant motion during the Day and Evening shifts until 11 p.m. and if a Resident fell during these shifts, then they are to leave the Resident on the floor, call for help from the nursing staff for a head-to-toe assessment." "There has also been an attempt to stop more falls by having residents wear non-skid socks instead of shoes, and mats are for residents who fall frequently. Also a night light is provided in the rooms with low level illumination for someone that tries to get up."In an interview on 7/1/14 at 10:40 a.m., the DON reiterated that the facility's fall precaution program for Station 3 & Station 4 consisted of "Hall Monitors walking up and down the hall constantly in motion looking and hopefully preventing a fall from occurring. If something more should be done, it will depend on the needs of the resident and we discuss this in morning rounds, I am also contacted at home if there is a more serious injury during the night." We also have Physical Therapy help us determine about whether a fall mat should be put in place, it all depends on what the individual needs. We have even tried moving furniture around in an effort to have an effect on falling behavior." In an interview on 7/21/14 at 3:20 p.m., Licensed Vocational Nurse 2 (LVN 2), stated he worked the night shift as the charge nurse since January 2014. LVN 2 stated Resident 2 usually wandered between Stations 3 & 4 during the night shift, however she could be redirected. LVN 2 stated there was no particular reason for Resident 2's room being at the end of the hallway and, "Resident 2 falls sometimes because she won't have her nonskid socks on and she'll get out of her bed or turns around too, quickly." LVN 2 also stated that regarding fall precautions, "The facility makes sure that the bed is in the low position, that there are no environmental issues, no clutter in the room, and that a night shift CNA will monitor the hallway assisting residents to the bathroom as needed". LVN 2 stated that the facility, "Hasn't used any fall mats on Station 3 and he was not sure when or if any have ever been used there." The facility's undated policy and procedure entitled, "Falls and Fall Risk, Managing" showed the, "Facility staff along with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls, initiate approaches that might include rearrangement of room furniture, will implement additional or different interventions, or indicate why the current approaches remain relevant, or if underlying causes cannot be readily identified or corrected staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped." 2. During an observation on 4/30/14 at 2:45 p.m., Resident 1 was lying flat in bed asleep. Resident 1's bed was in the lowest position and was pushed directly against the wall next to him. Resident 1's bed had the upper left half side rail raised, with a comforter partially thrown over it. Upon further observation, the top of Resident 1's hands had deep, dark bluish-purple discolorations covering three fourths of both his hands.In an interview on 4/30/14 at 2:47 p.m. regarding the discolorations on Resident 1's hands, LVN 1 stated, "He always hits and bangs both of them against the wall and the side rail to get our attention." Review of the medical record on 4/30/14 showed that Resident 1 was admitted to the facility on 1/6/12 and that Resident 1 had diagnoses which included dementia, anxiety fainting and a recent ankle fracture due to a fall. A Physician's order, dated 10/5/13, for Aspirin 81 milligrams daily. (Prolongs clotting time to prevent unwanted clotting) The Minimum Data Set, (assessment) dated 1/30/14 reflected Resident 1's ability to make himself understood was limited to concrete requests and that his decisions were poor and he needed staff prompts and supervision daily. A fax cover sheet was sent on 3/9/14 to Resident 1's physician with the following information, "Skin discoloration to left posterior hand; purple with no open areas or tender to touch. Approximately 3 by 3 centimeters, irregular in shape. Able to move with full range of motion to hand and fingers, no complaints of pain." Unknown causes, no falls or incidents seen will continue to monitor for three days". The physician's order, dated 3/10/14, showed, "Yes, monitor". A Nursing Care plan for Resident 1 originally dated 11/6/12 with no update showed that Resident 1, "Hits the bed rail and wall when agitated," The goal was he, "Would have no episodes of hitting the wall or bed rail."A second Nursing Care plan dated on 4/30/14 showed that Resident 1 had multiple discolorations on both his left and right hands and that staff would, "Prevent Resident 1 from hitting and banging walls" and that Resident 1 would, "Wear long sleeves." Therefore, the facility failed to protect Residents 1 and 2 from accidents with injuries. These failures had a direct or immediate relationship to the health, safety, or security of patients. |
| 140000136 |
San Miguel Villa |
020011276 |
B |
13-Feb-15 |
DGWP11 |
8199 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICESThe facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility violated the aforementioned regulation when they failed to:1. Ensure Resident 1 received adequate supervision and safety precautions when she was allowed to sleep in a bedside chair; 2. Evaluate a bedside chair as being safe for sleeping;3. Prevent Resident 1 from slipping out of the bedside chair, sustaining a fracture of the thigh bone, resulting in an avoidable hospital stay and surgery. Resident 1 was a frail resident, admitted on 5/9/14 with diagnoses that included Alzheimer's disease (loss of memory that affected daily life). The facility reported that on 9/13/14 at about 9:10 p.m. Resident 1 fell from a bedside chair, sustaining a hip fracture. In an interview on 9/19/14 at 10:30 a.m., the Director of Nursing (DON) stated Resident 1 preferred to sleep in her bedside chair frequently. DON added that the facility could not impose on Resident 1 to sleep in her bed. It was added to the care plan that Resident 1 preferred to sleep in her bedside chair. DON said Resident 1 was offered assistance with her activities of daily living if she needed assistance; otherwise, Resident 1 was encouraged to be as independent as she could be. (Independent, no help or staff oversight at any time) [Reference: MDS 3.0 RAI Manual Version 1.11.2 Effective 10/01/2013]. Review of the activities of daily living functioning care plan, dated 5/9/14, showed Resident 1 was to have limited assistance for mobility (staff provides guided maneuvering of limbs or other non-weight bearing assistance).The fall risk care plan dated 5/9/14, showed Resident 1 preferred to sleep in her bedside chair. To avoid any serious injuries from falls, one of the approaches the facility planned was to keep the call light within Resident 1's reach to call for help when she was in bedside chair, however Resident 1's memory loss would probably prevent her from remembering to use the call light. The care plan did not show any other interventions that assured Resident's 1's safety in using the bedside chair to sleep in.During an interview and concurrent record review on 9/19/14 at 10:45 a.m., Licensed Vocational Nurse (LVN) 1 stated Resident 1 was a non-compliant resident and one who would forget instructions like calling for help. The Physician's Progress Notes dated 8/14/14 showed that Resident 1 was confused. In an interview and concurrent record review on 9/19/14 at 11:40 a.m., DON confirmed Resident 1 had a prior fall on 6/12/14 at 3:45 p.m. The Alas Fall Risk Evaluation (an assessment tool used to measure a resident's risk of falling), dated 8/16/14, showed Resident 1 had a score of nine which meant that she was not considered high risk for Falls. In that same evaluation form, under the item, "History of falls (past 3 months)," Resident 1 was given a score of zero, which meant that she did not have any fall in the past three months. DON confirmed the fall risk assessment was incorrect, because the fall incident on 6/12/14 (two months prior to the assessment) should have been included. DON said that would have made the score, "11," a high risk for falls. The Alas Fall Risk Evaluation showed, "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." DON said if Resident 1 was considered a HIGH RISK for falls, the care plan would have been changed to add few more interventions for fall precautions. During an interview on 9/23/14 at 4:06 p.m., Registered Nurse (RN) 1 stated fall risk evaluations were done by licensed nurses every three months. RN 1 also said if the fall risk assessment found Resident 1 to be at high risk for falls, the level of assistance reflected on the care plan would change from independent assist (no help or staff oversight at any time) to supervision (oversight, encouragement or cueing from staff). RN 1 said at the time of the fall, when he responded to LVN 1's call for assistance, he saw Resident 1 on the floor in front of the bedside chair, which was slightly tilted forward. RN 1 also said he was not sure if the chair was appropriate for her size and Resident 1 probably needed a chair that was, "More suitable for her." RN 1 stated he was not sure if the Interdisciplinary Team (IDT-a team of facility staff composed of different department heads) had a discussion concerning safety of the bedside chair that Resident 1 preferred to sleep in. In an interview on 9/19/14 at 11:12 a.m., Certified Nursing Assistant (CNA) 1 stated on the night of 9/13/14 around 8:00 p.m., he went into Resident 1's room and found Resident 1 in the toilet and he helped her back to the bedside chair because she refused to sleep in her bed. CNA 1 said after he assisted Resident 1 to her bedside chair, he left the room to take care of another resident. When he went back into Resident 1's room to provide care for Resident 1's roommate around 9:00 p.m., he saw Resident 1 on the floor, in a sitting position with her back against the bedside chair and her head resting on the chair seat. CNA 1 stated he asked Resident 1 what happened, and Resident 1 answered that she slipped out of the chair.In another interview on 9/19/14 at 10:45 a.m., LVN 1 stated Resident 1 refused to sleep in her bed, and wanted to sleep in her bedside chair instead. LVN 1 also said when she went into Resident 1's room after she was told of the fall incident, Resident 1 had told her she fell asleep and slipped out of the chair.In an observation and concurrent interview on 9/26/14 at 3:49 p.m., the bedside chair located to the left side of Resident 1's bed was a regular upright wooden non-reclining chair that had a thin cushion and wooden arm rests. DON confirmed it was the bedside chair that Resident 1 fell from. During a follow up interview on 9/30/14 at 11:50 a.m., DON confirmed there was no documentation to show Resident 1's use of the bedside chair to sleep in was ever assessed by the IDT (Interdisciplinary) team. There was nothing in the record regarding the reason Resident 1 refused to sleep in her bed.On 9/30/14 at 1:30 p.m., Occupational Therapist (OT) 1 stated the rehabilitation department did not see Resident 1 until after the fall incident. OT 1 also said the nursing department did not involve the rehab to determine safety of Resident 1 when using the bedside chair. OT 1 added if she had been asked to get involved in the assessment, she would have assessed possible reasons why Resident 1 did not want to sleep in her bed.In an interview on 10/1/14 at 9:05 a.m., CNA 3 stated she saw Resident 1 sleep in the bedside chair a number of times even before the fall. CNA 3 also said Resident 1 did not like to sleep in her bed because she was not comfortable and that Resident 1 once told her she, "doesn't feel good" in the bed. On 9/13/14 an x-ray was done after Resident 1 complained of pain on her right hip. The x-ray report showed Resident 1 had a fracture of her thigh bone. She was sent to the hospital for further evaluation on 9/14/14 at 2:00 a.m. A review of the Emergency Department (ED) Provider Notes signed on 9/15/14 at 8:50 p.m. showed Resident 1 had pain that was described as 10 out of 10 (the worst possible pain) with associated vomiting, nausea, and shortness of breath. The ED notes confirmed fracture of the right femur (thigh bone) was confirmed by x-ray. The assessment dated 9/14/14 showed Resident 1 underwent surgery to repair it. Therefore the facility violated the aforementioned regulation when they failed to: 1. Ensure Resident 1 received adequate supervision and safety precautions when she was allowed to sleep in a bedside chair; 2. Evaluate a bedside chair as being safe for sleeping;3. Prevent Resident 1 from slipping out of the bedside chair, sustaining a fracture of the thigh bone requiring an avoidable hospital stay and surgery. These failures had a direct relationship to the health safety, or security of patients. |
| 140000136 |
San Miguel Villa |
020011279 |
B |
13-Feb-15 |
None |
7422 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICESThe facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility violated the aforementioned regulation when they failed to: 1. Provide sufficient supervision to prevent three falls in one week, and 2. Practice the safety measure of locking wheelchair brakes when Resident 1 was left alone and fell sustaining a hip fracture and undergoing surgery and a hospital stay. Record review on 9/30/14, showed the facility readmitted Resident 1 from the hospital, on 7/23/14, with multiple diagnoses that included dementia (loss of memory). The fall risk assessment dated 7/23/14 showed Resident 1 was at high risk for falls, was to be assisted to walk and should be placed near the nurses' station. Review of the clinical record and Minimum Data Set Assessment (MDS- an assessment tool used to direct resident care), dated 5/23/14, showed Resident 1's ability to think and reason was severely impaired.Nurse's notes and the care plan showed the following: -On 7/24/14, Resident 1 was found on the floor near the nurses' station. Resident 1 sustained a skin tear to her right eyebrow. The fall incident was unwitnessed.Physical therapy (PT) notes, dated 7/24/14, regarding functional status, showed Resident 1 needed moderate staff assistance when moving in her wheelchair. The functional notes showed PT notified the nursing staff and the certified nurse aide (CNA) staff that Resident 1 required constant supervision.A Patient Care Plan update, dated 7/24/14, showed care plan approaches for a fall that included closer observation, proper use of the wheelchair, redirecting Resident 1 as needed, continue physical therapy and placing Resident 1 near the nurses' station. The care plan did not reflect a need for Resident 1 to have constant supervision. According to nurses' notes, dated 7/27/14 at 6:20 a.m., facility staff found Resident 1 on the pavement in the patio, lying on her left side. Resident 1 had sustained a skin tear to the forehead and left hand, and abrasions to both knees. The fall incident was unwitnessed.The Patient Care Plan, dated 7/27/14, showed entries for interventions that included keeping Resident 1 near the nurses' station and, "Keep me in site (sight) when awake." According to nurses' notes, dated on 7/29/14 at 5:20 p.m., Resident 1 fell when she stood up from her wheelchair, lost balance, and slowly slid from the wheelchair. Resident 1 landed on her buttocks. There was no injury. The Patient Care Plan, dated 7/29/14, recorded approaches for falls as continuation of physical and occupational therapy and, "Monitor for 72 hours."Nurses' notes, dated 7/30/14 at 8:04 a.m., recorded that Resident 1 fell three times in one week. Continued nurses' notes, dated 7/30/14 at 12:39 p.m., showed Resident 1 could not participate in physical therapy. Resident 1 was noted to have swelling, slight redness and decreased motion of her left hip and right knee. An x-ray showed a left hip fracture and Resident 1 was sent to the hospital. In an interview, and concurrent record review on 11/19/14 at 8:40 a.m., Director of Nursing (DON) said that a resident's care plan should be revised if there was a new fall incident.The Patient Care Plan, dated 7/24/14 through 7/29/14, did not list any new interventions to prevent falls. DON also stated that since Resident 1's fall, the facility had developed a new fall protocol because DON said, "We're missing something." DON said that if a resident falls, the Interdisciplinary Team (IDT) should gather around the resident to determine what had caused the fall and then proceed to explore possible ways to avoid another fall. DON stated the only other IDT note found in Resident 1's clinical record was dated 7/17/14; done after Resident 1's unobserved fall in the dining area. There were no IDT notes done after Resident 1's falls on 7/24/14 and 7/27/14. The fall care plan, dated 7/23/14, did not show that it was updated or revised with new approaches or interventions after Resident 1's multiple falls.Review of the facility's policy and procedure titled "Care Plans-Comprehensive," revised October 2010, showed resident assessments were ongoing and care plans were to be revised as information about the resident's condition changed. It also showed the Interdisciplinary Team (IDT, facility staff representing different departments) is responsible for reviewing and updating care plans when there is a significant change in resident's condition and when the desired outcome has not been met. In an interview, and concurrent record review, on 9/30/14 at 2:07 p.m., Registered Nurse Supervisor (RNS) stated, a post fall investigation was done and confirmed the wheelchair rolled back behind Resident 1.The Interdisciplinary (IDT) Progress Notes, dated 7/29/14, showed Resident 1 attempted to get up from her wheelchair, the wheelchair slid back and Resident 1 dropped to a sitting position on the floor.The IDT notes showed "It is suspected that the (wheelchair) brakes were not applied." During an interview on 9/30/14 at 3 p.m., Director of Staff Development (DSD) stated, for resident's safety, wheelchair brakes need to be applied when leaving residents in their wheelchairs especially those who are at high risk for falls.Review of the Look-Back Report dated 7/27/14 showed Resident 1 was wheeled to activities with moderate assist from staff. Review of the MDS dated 5/23/14 showed that Resident 1 was not able to move to or from distant areas within the facility such as the dining or activities rooms without help from staff.In an interview on 11/19/14 at 9:40 a.m., Occupational Therapist (OT) stated that for safety of residents who are cognitively impaired and are not able to lock their wheelchairs, "it's automatic. I have to lock the wheelchairs even if I leave them near the nurses' station, for safety reasons." OT said that these residents who are on wheelchairs don't have adequate muscle strength, so that when they try to stand up and the wheelchair is not locked, wheelchair might slide backwards and they fall. Review of the Occupational Therapy Notes (OT) and Physical therapy (PT) notes dated 7/24/14 showed that Resident 1 needed moderate staff assistance to move the wheelchair.-PT notes dated 7/25/14 showed that Resident 1 was impulsive and attempted to stand and walk away when not monitored. -OT notes dated 7/27/14 showed that Resident 1 was not safe when in wheelchair and required constant supervision as Resident 1 frequently attempts to stand and ambulate without assistance. -PT notes dated 7/28/14 showed that Resident 1 was anxious and made multiple attempts to stand without assistance. Review of the hospital Emergency Department (ED) notes, dated 7/30/14, showed diagnoses for Resident 1 that included a hip fracture. Surgery was done on Resident 1's left hip on 7/30/14. Resident 1's hospital stay was 29 days and she was discharged back to the facility. Therefore the facility failed to provide sufficient supervision to prevent accidents and practice the safety measure of locking Resident 1' wheelchair brakes when she was left alone. She fell and sustained a hip fracture, which required surgery and a hospital stay. These violations had a direct relationship to the health, safety or security of patients. |
| 140000733 |
Stonebrook Healthcare Center |
020011831 |
B |
05-Nov-15 |
WO0I11 |
5526 |
483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICESThe facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility violated the aforementioned regulation by failing to provide supervision for Resident 1 on 11/19/14 while he was in a wheelchair. Resident 1 was unable to sustain an upright position in the wheelchair due to left sided contractures and weakness and the speech therapist took off her seat belt and left her unattended in the wheelchair, resulting in Resident 1 falling out of the wheelchair and fracturing her skull and elbow. Record review on 12/10/14 showed Resident 1 was admitted to the facility on 10/27/14, with diagnoses that included general muscle weakness, malnutrition, and stroke with left hemiplegia (paralysis on one side of the body). A physician's order, dated 11/22/14, showed "Patient [Resident 1] does not have capacity to make healthcare decisions." The complete resident assessment, dated 11/17/14, showed Resident 1 required the extensive assistance of one staff for bed mobility, dressing and hygiene, assistance of two staff for transfer from bed to chair, for toilet use, and for bathing. It showed, "Moving from seated to standing- Only able to stabilize with staff assistance. Uses a wheelchair." Review of Resident 1's Fall Risk Assessments showed that on 10/27/14, the score was 10 and on 11/2/14, the score was 14. A score of 10 or more meant there was a high risk for falls. Review of a care plan, dated 10/27/14, showed "Impaired Cognition (thought process) related to stroke; Goal- Will understand simple statements and commands. Interventions- Encourage to attend activities, Minimize distractions, reality orient." A care plan, dated 10/28/14, showed, "Focus: Mobility deficit related to stroke and fall risk due to weakness and unsteady gait." A care plan, dated 10/31/14, showed "Preventing Falls." The interventions were "Keep call light nearby and monitor frequently." Review of nurses' notes, dated 10/27/14, showed "[Resident 1]Alert and forgetful. Sit upright for dinner. Fed by staff." A nursing note, dated 11/19/14, signed by RN 1, showed, "Notified to come to patient's room at 10:50 a.m. Noted patient lying prone (face down) on the floor with abrasion to the left forehead with minimal bleeding noted. Also noted abrasion on the left hand. Patient able to move right arm and leg. ...Patient complained of pain but unable to tell exactly where he is hurting. Called 911 and sent to hospital." Review of the hospital emergency department social worker's notes, dated 11/19/14, showed, "When his therapist went to get something..., patient fell forward from the wheelchair and hit his head. Per relative,..., who is at bedside, patient generally stoic about pain but reporting pain at level 8 (out of 10) in left wrist. Patient has a reclining wheelchair and has never fallen out of it. Relative described that it would not be possible to fall out of it when at a reclining angle due to positioning and patient's hemiplegia. Nonetheless, when speech therapy was working with patient and left patient alone, patient fell out of chair."Review of the hospital emergency department showed a skull fracture seen on a CT (computerized tomography) scan, extending into the left frontal sinus and orbital roof (eye area) and a left elbow fracture. During an interview and concurrent record review on 12/10/14 at 10:00 a.m., the Assistant Director of Nurses (ADON) stated, "I assessed him after the unwitnessed fall. He was sitting on the floor next to his reclining wheelchair. He was alert and giving one word answers. He tends to lean forward which makes him unsteady. A couple of days before the fall, family brought in the reclining wheelchair. He was sitting upright in our (facility) wheelchair before that and he didn't fall." ADON confirmed that no new interventions or information was added to the fall prevention care plan after the 11/19/14 fall.During interview on 12/10/14 at 10:30 a.m., the Director of Nurses (DON) stated, "We know why he [Resident 1] fell. She [physical therapist] left him at a ninety degree angle and he always falls when he is sitting upright. We found this out after he fell." During observation and interview on 12/10/14 at 2:20 p.m., Resident 1 was sitting in an upright position in his bed. He stared straight ahead and stated, "I hurt my arm." A splint was on his left forearm which was elevated on a pillow.During a phone interview on 12/26/14 at 10:35 a.m., the Speech Therapist (ST) stated, "He had been in physical therapy before he came to me. We went to his room for oral care before I started to test swallowing deficits. He had an NG tube (naso-gastic tube inserted through the nostril into the stomach for liquid food, fluids and medication) but the family wanted him to be able to eat for pleasure. I ran out of the room to grab a towel when he started drooling. He was leaning back a little when I left him. I went back into the room with a CNA who heard him fall. I wasn't aware of any precautions or that he shouldn't be left alone. I didn't check with anyone about whether he could be left alone." Therefore the facility failed to provide supervision for Resident 1, leaving her alone in her wheelchair resulting in Resident 1 sustaining a fall, fracturing her skull and elbow. The above violation has a direct relationship to the health, safety or security of patients |
| 020000629 |
Sunshine ICF/DDH #4 |
020012337 |
A |
16-Jun-16 |
81EI11 |
7916 |
W 318 483.460 HEALTH CARE SERVICES The facility must ensure that specific health care services requirements are met. W 337 483.460(c)(3)(iv) NURSING SERVICES Nursing services must include, for those clients certified as not needing a medical care plan, a review of their health status which must be recorded in the client & apos;s record. W 338 483.460(c)(3)(v) NURSING SERVICES Nursing services must include, for those clients certified as not needing a medical care plan, a review of their health status which must result in any necessary action (including referral to a physician to address client health problems). W 340 483.460(c)(5)(i) NURSING SERVICES Nursing services must include implementing with other members of the interdisciplinary team, appropriate protective and preventive health measures that include, but are not limited to training clients and staff as needed in appropriate health and hygiene methods. During an investigation of a reported event on 3/24/15, the Department determined through interview and record review, the facility violated the aforementioned regulation when it failed to: 1. Assess, monitor and implement a treatment plan when client G exhibited an increasing frequency of swallowing non-food items (pica). (An eating disorder manifested by a craving to ingest any material not fit for food, including starch, clay, ashes, toy balloons, crayons, cotton, grass, cigarette butts, soap, twigs, wood, paper, meta, or plaster. (Taber's Cyclopedic Medical Dictionary). 2. Notify the client's physician of the increasing frequency of the pica behavior. 3. Train the direct care staff on how to prevent, monitor and assist clients with pica behaviors. 4. Provide medical, psychological and behavioral services in order to treat the client's pica. Client G was a 62 year old male who lived at the facility for 27 years. He had a long standing history of pica. On 3/20/2015 at 2 p.m., Client G collapsed on the floor and stopped breathing. The staff started cardiopulmonary resuscitation and called 911. The emergency medical technicians removed 2 latex gloves from the back of his throat and transported him to the hospital where he subsequently died due to prolonged lack of oxygen to the brain (anoxia). An additional 12 latex gloves were recovered from his digestive tract. During an interview and concurrent medical record review on 3/24/15 at 6 p.m., the facility (RN) Registered Nurse stated Client G had a problem with eating non edible items. The RN stated lab work was intended to be drawn from Client G to determine if there was possible a medical cause for why Client G's behaviors were increasing with such intensity, but the lab work was not drawn. The RN was not able to find any documentation to show she notified the physician when Client G's behaviors intensified. There was no documentation by the physician that addressed Client G's pica condition. There was no documentation to show RN reviewed Client G's health status. There was no update to the care plans for grabbing/stealing food, and eating nonfood items. There were no notes to show the RN communicated with the interdisciplinary team (IDT- physician, Qualified Intellectual Disabilities Professional, direct care staff, administrator, nurse, dietician, other clinicians involved in a client's care) about Client G's health status, or increase in seeking and eating nonfood items. Medical record review, on 3/24/15, of the nursing notes from 10/5/14, through 3/20/15, showed one to two line entries documenting vital signs, weights, diagnoses, visits to an audiologist, and an optometrist. Two entries were for, "Pharmacy: Quarterly review." There was no documentation to show details of the pharmacy review, any follow-up or changes considered. Client G's Behavior Plan titled, "Pica - ingesting non-food items," (undated) showed the objective as: "Reduce the number of times he ingests a non-food item to 0 times a month, for six months by 5/31/15." There was a form designed for staff to record the dates, times, and details of pica incidents. The form was blank. There was no evidence to show the nurse instructed staff to document incidents of seeking and eating nonfood items. There was no evidence to show the RN, physician, or Qualified Intellectual Disabilities Professional reviewed the form, questioned staff about why it was blank, or trained staff in the importance of recording the information. Review, on 3/24/15, of a special incident report from the regional case manager showed, "[Client G] had been having a reported pica problem at the day program since about mid-February. Since then, on two occasions the client ingested a candy wrapper, banana peel, and corn apparently at the day program, and a napkin at home." During an interview on 3/24/15 at 7 p.m., the Program Manager (PM) stated an emergency IDT meeting was held on 3/4/15 because of Client G's ingesting nonfood items. The PM stated the day program staff expressed concern about Client G's escalating pica behaviors. They were having problems developing strategies to manage Client G's pica behaviors. The day program administrator requested the facility consult with the physician, psychologist, and dietician, to help Client G control his undesirable behavior. During concurrent record review with the PM of Client G's clinical record, the PM stated she was not able to locate any documentation that the medical or behavior doctor was informed about Client G's escalating pica behaviors. There was no entry to show the nurse reviewed Client G's health status with the physician, psychologist, or dietician regarding pica. There was no update to the "Pica" care plan, or evidence that the RN instructed staff in strategies to protect Client G from eating items that were not food. The "Q-Notes" (Qualified Intellectual Disabilities Professional's note)(QIDP), included an entry dated 3/11/15, showing the QIDP consulted with the facility RN about Client G's increased food seeking behaviors, and inquired about any medical intervention available. The RN responded that she had consulted with Client G's physician (unclear when consultation took place), and this was a long standing behavioral issue. The RN told the Program Manager she would request new lab work from the physician and discuss possible interventions. In an interview with Client G's physician, on 7/1/15, at 3 p.m., he stated the nurse did not call him to discuss Client G's worsening pica behavior, or to ask for blood work to investigate the reason for the changes in his behaviors. There was no documentation in the clinical record to show a consultation with Client G's physician. Further record review did not reveal documentation of a call to the physician, a request for blood work, and order for blood work, or lab results. In an interview with DCS 1 on 6/25/15, at 3:45 p.m., she stated she was not instructed to record incidents of eating nonfood items on a log, to report the incidents, or strategies to prevent them. In an interview with DCS 6, at 10 a.m. on 6/27, DCS 6 stated he saw Client G pick up candy wrappers and other small items and put them in his mouth. He stated he was not instructed to record incidents of pica behavior on the log, to report when he witnessed Client G eating nonfood items, or how to prevent the behavior. In an interview on 3/24/15, at 4 p.m., DCS 4 stated, "I don't know what pica is." Therefore, the facility failed to initiate health measures to protect Client G from inappropriately eating nonfood items. The nurse failed to inform the physician of a worsening pica behavior, to train facility staff in recognizing pica behaviors, and failed to implement possible interventions to prevent pica and its health hazardous consequences. This above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 030001827 |
Saint Claire's Nursing Center |
030008941 |
B |
30-Jan-12 |
286J11 |
7774 |
F323 - 453.25 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 to the facility on 6/19/09 at 2:53 p.m. to investigate complaint number CA00192441. As a result of the investigation it was determined that the facility failed to: 1. Provide adequate supervision or assistive device to prevent an accident.2. Ensure the resident environment is as free from accident hazards as is possible.The complainant alleged Resident 1 had eloped from the building on 5/24/09 and Resident 1's absence was undetected by staff until Family Member 1 (FM 1) arrived to visit and discovered Resident 1 could not be located in the building. Resident 1 was a 91 year old female who was admitted to the facility on 6/07/07 with diagnoses which included dementia with psychotic features, diabetes and a seizure disorder. According to the annual Minimum Data Set (MDS, an assessment tool) dated 5/25/09, the resident had moderately impaired decision making skills and short term and long term memory problems. The resident required the assistance of one staff member for most activities of daily living and could propel her wheelchair around the facility independently. The MDS revealed there had been no episodes of wandering (such as leaving the building) in the seven days prior to the assessment. Resident 1 was observed on 6/19/09 at 3:25 p.m. in her wheelchair in the hall near the nurse's station. She was alert and talkative. Resident 1 was observed at 3:40 p.m. to have an exit alarm on her right ankle, covered by her sock.At 3:45 p.m. on 6/19/09 three exit doors to the facility were observed to have exit alarm sensors on each side of the doors. In an interview with FM 1 on 6/30/09 at 10:00 a.m. she stated she visited Resident 1 during Memorial Day weekend 2009 around 4:00 p.m., (5/24/09). When she arrived she did not find Resident 1 in her room or in the hall or the dining room. She asked several staff members if they knew where Resident 1 was and they searched the whole building. FM 1 stated "A nurse said we should look in the parking lot, and we found her in the second row of cars." FM 1 stated Resident 1 told her she was trying to catch a bus to Richmond. FM 1 stated there was no alarm on the resident, nor was the door alarm sounding. During an interview with the Social Services Designee (SSD) on 6/30/09 at 11:30 a.m., she stated Resident 1 had two prior episodes of elopement from the building. She stated Resident 1 had worn an exit alarm band since admission, but the resident was known to be able to remove the band. She stated the exit alarm band triggered the door alarms when residents wearing the band came close to the exit door. SSD stated Resident 1 often wanted to go home in the afternoons. She stated on the weekends it was harder for staff to respond to exit alarms because the front office desk near the exit was not staffed on weekends. In an interview with AS 1 on 6/30/09 at 12:00 p.m., she stated Resident 1 had tried many times to leave the building since her admission to the facility.Resident 1's clinical record contained the following documentation: A Social Services Update, marked as quarterly, dated 11/25/08 revealed "At times she will try to leave facility saying she has to go home." A Social Services Update, marked as quarterly, dated 2/23/09 revealed "Has AWOL (absent without leave) attempts when agitated," and "Has been saying she has to go home." An Interdisciplinary Long Term Care Plan dated 3/08/08 which listed the problem "Wanders out of the facility." Under approaches are listed "visually check location of resident at least every 2 hours" and "Avail use of a (Brand name of alarm device system)." A Social Service Update note marked as annual and dated 05/23/09 revealed "Resident has had AWOL (absent without leave) attempts." A nurse's note dated 5/24/09 at 4:45 p.m. revealed "At 4:45 p.m. found this resident outside near the front door ....started to do an every hour monitoring whereabouts due to AWOL attempts." A short term care plan dated 5/24/09 listing the problem "AWOL attempts" and under approaches it listed "wrist alarm intact." A document titled Wandering Care Plan dated 5/30/09. No Interdisciplinary Progress Notes were located for the period after the incident. A Social Progress Note dated 6/01/09 indicated the resident became combative when redirected from exiting the building. The note revealed "redirecting not always successful." The note indicated "nursing will contact primary activity assistant for doing a one-on-one for emotional support and giving her focus on something other than trying to leave." Review of Physician's Orders for the months of May and June 2009 revealed no orders for an exit alarm band. Review of IDT notes for 2009 revealed multiple falls when the resident stood from her wheelchair. A chair alarm was in place to notify staff of her attempts to get up unassisted. In an interview with LN 1 on 7/14/09 at 2:22 p.m. she stated Resident 1 had "a big problem with wandering" and she was good at removing the alarm bracelet. LN 1 stated the resident usually tried to leave around dinner time. She was asked if the exit alarm sounded on 5/24/09 when Resident 1 left the building, LN 1 stated "I'm not sure." She stated "Once they hit the door we hear it, if it's working."During an interview with Licensed Nurse2 (LN 2) on 7/14/09 at 2:30 p.m. she stated on 5/24/09 around dinner time, when FM 1 asked her to help locate Resident 1, she checked in the room and the dining room. LN 2 stated she looked around the building for about 2 minutes and then found Resident 1 outside the front door in her wheelchair next to the benches. LN 2 stated "the alarm didn't work, battery was dead." When asked if the wrist band was on Resident 1, she stated "I think so." LN 2 stated staff put new exit alarm bands on Resident at that time, one on her ankle and one on the wheelchair as backup. In an interview with Licensed Nurse 3 (LN 3) on 7/14/09 at 3:10 p.m. she stated exit alarm batteries needed to be replaced every 90 days. She stated they are checked for battery charge and replaced as needed. LN 3 stated a log was kept of exit alarm battery checks. During a concurrent observation with LN 3, Resident 1 was observed to have an exit alarm band on her right ankle. The band was marked with the date "5/26/09."In an observation on 7/14/09 at 2:50, the exit door alarms were observed to sound loudly at the exit door. The nurse's stations are in the center of the building 94 paces away from the exit door and there was not an alarm speaker near the nurse's station. The street where the facility is located is a mix of business property of the same side of the street as the facility and residential property on the opposite side. The alarm monitoring system documents for six months, (January 2009 through June 2009) indicated Resident 1 was listed on each month's record. Check marks or lines were observed on every day of each month listed. There were no indications when the batteries were changed for any of the residents on the log. The facility failed to protect Resident 1 from health and safety hazards when she was known to be an elopement risk and have frequent falls, and the facility failed to: 1. Provide adequate supervision or 2. Provide an effective alarm system to protect the resident from an accident.As a result, Resident 1 was found outside the facility without the knowledge of staff.These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility resident s or residents. |
| 030001827 |
Saint Claire's Nursing Center |
030008942 |
B |
30-Jan-12 |
286J11 |
7319 |
F202 - 483.12 Documentation Of Transfer/discharge Of Resident (a)(3) When the facility transfers or discharges a resident under any of the circumstances specified in paragraph (a)(2)(i) through (v) of this section, the resident's clinical record must be documented. The documentation must be made by the resident's physician when transfer or discharge is necessary under paragraph (a)(2)(i) or paragraph (a)(2)(ii) of this section; and a physician when transfer or discharge is necessary under paragraph (a)(2)(iv) of this section. F203 - 483.12 Notice Requirement Before Transfer/discharge (a)(4) - (6) Before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; record the reasons in the resident's clinical record; and include in the notice the items described in paragraph (a)(6) of this section. Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged. Notice may be made as soon as practicable before transfer or discharge when the health of individuals in the facility would be endangered under (a)(2)(iv) of this section; the resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (a)(2)(i) of this section; an immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (a)(2)(ii) of this section; or a resident has not resided in the facility for 30 days. The written notice specified in paragraph (a)(4) of this section must include the reason for transfer or discharge; the effective date of transfer or discharge; the location to which the resident is transferred or discharged; a statement that the resident has the right to appeal the action to the State; the name, address and telephone number of the State long term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. F204 - 483.12 Preparation For Safe/orderly Transfer/discharge (a)(7) A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. An unannounced visit was made on 6/19/09 to initiate investigation of Complaint CA00192441. The complaint was related to Resident's Transfer and Discharge Rights. An Administrative Hearing was held at the facility on 6/30/09 at 9:15 a.m. to appeal the proposed discharge of Resident 1.As a result of the investigation and review of The Summary of Findings from the Hearing Officer, it was determined that the facility failed to:1) Document the physician's reason for a proposed discharge of Resident 1 to a lower level of care. 2) Issue notification with 30 days advance notice and (2) to identify a viable setting for discharge of Resident 1 in the written notice. 3) Provide adequate orientation and preparation for a safe and orderly move and failed to develop a discharge or post-discharge plan of care to identify how Resident's continuing care needs would be met. Resident 1 was a 91 year old female admitted to the facility on 6/07/07 with diagnoses which included dementia with psychotic features, diabetes and a seizure disorder. According to the annual Minimum Data Set (MDS, an assessment tool) dated 5/25/09, the Resident had moderately impaired decision making skills and short term and long term memory problems. The Resident required the assistance of one staff member for most activities of daily living and could propel her wheelchair around the facility independently. Review of the clinical record for Resident 1 revealed Physician's orders for May and June 2009 did not contain written instructions for discharge.Physician progress notes for May and June 2009 did not refer to any plans for discharge.IDT (Interdisciplinary Team) notes for May 2009 did not contain any reference to discharge for Resident 1. Review of a Notice of Proposed Transfer/Discharge for Resident 1 revealed the notification date filled in was 5/28/09. The notice effective date was listed as 7/01/09.Review of a cover letter for the Notice of Proposed Transfer/Discharge issued by Administrative Staff 2 (AS 2) had a date of 06/12/09 at the top. Review of the mailing envelope in which the cover letter and Notice of Proposed Transfer/Discharge were mailed to Resident 1's responsible party documented with a post mark of Jun 12, 2009.The Notice of Proposed Transfer/Discharge for Resident 1 indicated the intended discharge location was an address in Sacramento. In an interview with Family Member 1(FM 1) on 6/19/09 at 10:00 a.m. she stated "the address listed on the notice was my previous home address," but she "no longer lived at the address listed on the discharge notice." She stated she "left Sacramento in September 2008 to live in San Francisco."She stated that she was "not contacted to discuss the discharge plans for Resident 1." In an interview with Social Services Designee (SSD) on 6/30/09 at 11:30 a.m. she stated she had not heard of any discharge plans for Resident 1. She stated the Interdisciplinary Team coordinated plans for discharge. SSD stated Resident 1 was "not ready for a lower level of care." In an interview with AS 2 on 6/30/09 at 12:00 p.m. she stated she was the facility discharge planner and the admissions coordinator. AS 2 stated that discharge planning had not been done for Resident 1 and she "didn't anticipate discharge really when the discharge notice was sent out." She stated it was a "corporate decision to evict" the resident. AS 2 stated she was "not aware FM 1 had moved out of the area." The clinical records for Resident 1 revealed a Social Services Update dated 5/23/09. Under the heading Discharge Plan a check mark was added next to the statement "continues to need Long Term Care (LTC) due to (d/t) health care needs." Written under Remarks for the discharge plan was a hand written note "No anticipated discharge at this time." Therefore, the facility failed to1) Document the physician's determination of the resident's condition for discharge to a lower level of care.2) Provide sufficient notification prior to discharge of Resident 1 from the facility and specify an adequate setting for her care after discharge.3) Provide adequate orientation and preparation for a safe and orderly move and failed to develop a discharge or post-discharge plan of care to identify how Resident's continuing care needs would be met. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility Residents. |
| 030000067 |
Sacramento Post-Acute |
030008960 |
B |
01-Feb-12 |
CINF11 |
3203 |
Health & Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 11/5/10 an unannounced visit was made to the facility to investigate an Entity Reported Incident #CA00189469 related to an alleged Patient to Patient altercation.The Department determined the facility failed to report an allegation of abuse between Patient A and Patient B within the mandated reporting timeframe.Patient A was a 92 year-old female admitted to the facility on 7/6/07 with diagnoses which included a mental disorder and depression. Patient A's Minimum Data Set, (MDS- a standardized assessment tool) dated 4/22/09, showed that Patient A had short and long term memory deficits and modified independence (some difficulty in new situations only) in her cognitive skills. Patient A could be understood and was usually understood by others. Patient A did not exhibit any signs of depression, anxiety, or a sad mood and she was independent in walking and activities of daily living (ADL's).Patient B was a 57 year-old female admitted to the facility on 1/14/09 with diagnoses which included convulsions and left-sided weakness after a stroke. Patient B's MDS dated 4/25/09 revealed that she had short and long-term memory problems with moderately impaired cognitive skills. Patient B could be understood and was usually understood by others, although she had periods of disorganized speech. Patient B would, at times, exhibit socially inappropriate and disruptive behavior.A review of the report submitted to the Department by the facility on 5/22/09 read that Patient's A and B were observed kicking and hitting each other. A review of both patients' clinical record did not provide any dated documentation of whether or not either patient was hurt during the altercation. The facility could not pin point the actual date of the incident and what the investigation entailed. A review of Patient B's nursing notes, dated 5/19/10, indicated that Patient B had complained that her roommate, Patient A, had hit her on her left upper arm.A review of the facility's Administrative Abuse Policy & Procedure (P&P - revision 6/26/07) indicated, in part, under, "#14", that "anyone in the facility that observed possible/suspected abuse must report it promptly to supervisory personnel and the report should include the following information, involved Patient(s) name(s), date and time of occurrence, where and what happened, witnesses, and any other information needed for the investigation."On11/5/10 at 9:10 a.m., during the reviews of Patient A and B's medical record with the Director of Nurses (DON), she concurred that the facility was aware of the incident on 5/19/10 and it should have been reported no later than 5/20/09.The Department determined the facility failed to follow State Law and the facility's policy and procedure regarding alleged and suspected abuse reporting requirements. Failure to meet this section of the California Health & Safety Code shall be a Class B Citation. |
| 100000082 |
St. Jude Care Center |
030009691 |
B |
15-Jan-13 |
4MI011 |
5924 |
F282 Services by Qualified Person/per Care Plan 483.20 (K)(3)(ii) The services provided or arranged by the facility must meet professional standards of quality.F309 Provide Care/Services for Highest Well Being 483.25 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The following citation was written as a result of an unannounced visit to the facility for the investigation of complaint #CA00212891. The Department determined the facility failed to: 1. Ensure certified staff reported an accident involving a resident to supervisory staff. 2. Adequately assess and treat complaints of severe pain. Resident A sustained a fractured left ankle during an assisted fall that was not reported to Supervisory Nursing Staff. Resident A complained of severe pain that was not adequately assessed for a period of eleven hours before being transferred to the emergency room for evaluation and treatment. Resident A was a 62 year old admitted to the facility on 10/4/07. Her diagnoses included a stroke with left side paralysis and senile dementia. A Minimum Data Set (standardized assessment tool) dated 11/27/09 indicated Resident A had long and short-term memory impairments and modified cognition. She required extensive assistance from two staff persons to transfer and she was not able to walk. Resident A had no history of pain. Nurse's Notes dated 12/27/09 as a "late entry" for 12/26/09 at 6:30 p.m. included the following documentation. "Resident was noted crying and screaming. When asked what's wrong, resident continued to cry. When asked if she is in pain, she said yes. When asked where does she hurt. Resident stated "everywhere." Administered Tylenol 325mg 2 tabs at 5:45 p.m........10 p.m. Resident is noted starting to cry again and start to scream again asking for help. Resident was endorsed to Noc nurse." Nurse's Notes dated 12/27/09 at 1:10 a.m. included the following documentation. "Resident in room crying, yelling, screaming. Went to room c/o (complain of) extreme pain all over clinching left hand. Asked where she hurts. All over, please help me."Documentation in the note revealed Resident A's physician was notified and an order was received to send Resident A to the emergency room for evaluation. Resident A was transferred via ambulance to the emergency room at 1:30 a.m. Nurse's Notes dated 12/27/09 at 4 a.m. documented the Licensed Nurse (LN) telephoned the General Acute Care Hospital (GACH) where Resident A was transferred to check the resident's status. The LN was informed Resident A had a broken ankle. A Consultation dated 12/27/09 and completed at the GACH indicated Resident A was diagnosed with a left distal tibia fracture (fractured left ankle), which was treated with an orthopedic boot to stabilize the fracture. Resident A was re-admitted to the facility on 12/28/09 at 5 p.m. An Incident Report Follow-Up Investigation dated 12/28/09 revealed on 12/26/09 at 2:00 p.m. two Certified Nurse Assistants (CNA) were attempting to transfer Resident A from her wheelchair to her bed but were unable to lift the resident high enough to the bed and Resident A was assisted to the floor.CNA 1 wrote a declaration (undated) which indicated on 12/26/09 after assisting Resident A to the floor a third CNA was asked to help get Resident A off the floor and into her bed, which the three CNA's did. At the bottom of the declaration the LN who worked the day shift on 12/26/09, documented she had not been notified that Resident A had an assisted fall. CNA 2 wrote a declaration dated 12/27/09. CNA 2 documented she came on shift (12/26/09) at 2:30 p.m. and Resident A was crying and holding her hand stating, "I hurt." CNA 2 documented when she asked what hurt, Resident A could not say and just kept on crying. CNA 2 documented she changed Resident A and left the room but the resident did not stop crying. CNA 2 documented the LN went in the room and talked with Resident A. CNA 2 documented she went to assist other resident 's with their dinner and when she came back to Resident A's room the resident was "still crying the whole time until 10:30 p.m. when I left for home." Resident A's December 2009 Medication Record (MR) revealed Resident A's pain level was being monitored every shift. Resident A's pain was scored as 0, which equaled no pain on all shifts. On 12/26/09 on the evening shift Resident A's pain was scored as a 5, which equaled moderate pain. Documentation on the MR indicated on 12/26/09 at 5:30 p.m. Resident A was administered two Tylenol tablets for "generalized pain." An interview was conducted with the Director of Nurses (DON) on 01/21/10 at 11:40 a.m. The DON stated the two CNA's tried to put Resident A into her bed but couldn't lift her high enough and put her on the floor. The CNA's called another CNA into the room and the three CNA's lifted Resident A onto her bed. The DON stated the CNA's did not tell the LN that Resident A had been placed on the floor. The DON stated if a resident is assisted to the floor due to an aborted transfer attempt, that is considered a fall. The DON stated CNA 1 acknowledged she knew she was to notify the LN that Resident A was on the floor but she said she "forgot." The DON acknowledged that Resident A did not have a history of pain and the fact that she was crying and screaming in pain should have prompted licensed staff to fully assess Resident A for a change in her condition.The Department determined the facility failed to: 1. Ensure certified staff reported an accident involving a resident to supervisory staff. 2. Adequately assess and treat complaints of severe pain. These violations had a direct or immediate relationship to the health, safety or security of long-term care facility resident s or residents. |
| 100001810 |
Shirley's ICF/DD-H #4 |
030009773 |
B |
11-Mar-13 |
5J7211 |
3541 |
Health Support Services -- Nursing Services - 76875 (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. The following citation was written as a result of an unannounced visit on 9/29/10 for the Investigation of intake number CA00242264, a facility reported incident. The Department determined the facility failed to notify Client A's physician when Client A sustained an injury to her left ankle and was unable to ambulate. This failure resulted in a delay of approximately 22 hours before an x-ray was obtained to determine the extent of injury to Client A's left ankle. Client A was a 48 year old with diagnoses that included profound mental retardation. Information in the clinical record revealed Client A was able to ambulate with a gait belt (a belt that is placed around the client's waist that staff can hold to stabilize the client while ambulating) and staff assistance. Licensed Staff Notes, dated 12/21/09 at 2:45 p.m., revealed the facility received a call from Client A's day program requesting facility staff pick up Client A from the day program because she was unable to stand or walk and her left ankle was swollen. Licensed Staff Notes, dated 12/21/09 at 3:30 p.m., indicated Client A arrived home from the day program in a private car and she was "unable to place [weight] on [left] foot. [Complained of] pain and discomfort. Lifted on [wheelchair] and brought into home. Placed on armchair [with] leg elevated. [Left] outer ankle swollen, red." The next Licensed Staff Notes was dated 12/21/09 at 5 p.m. The Notes indicated Client A was still unable to walk due to pain and she was administered Tylenol 500 milligrams. Review of the clinical record revealed there was no further documentation regarding the condition of Client A's left ankle until the following day, 12/22/09 at 8 a.m. The Licensed Nurse documented the ankle remained red and swollen and Client A continued to refuse to ambulate. A telephone call was placed to Client A's physician. Licensed Staff Notes, dated 12/22/09 at 9:30 a.m., documented Client A's physician ordered an x-ray of the left ankle. At 12:30 p.m. Client A was taken to the diagnostic center for x-rays. Licensed Staff Notes, dated 12/24/09 at 10 a.m., three days after the injury to Client A's left ankle had been identified, revealed Client A's x-ray results indicated there was a non- displaced fracture of the tip of the left lateral malleolus (left outer ankle). Client A required the placement of an air cast splint that was applied on 12/28/09.An interview was conducted with the Qualified Mental Retardation Professional (QMRP) on 9/29/10 at 12:30 p.m. He stated he had conducted the investigation into how Client A had fractured her left ankle. He initially indicated that Client A had been taken to an urgent care clinic for x-ray of the left ankle when she was picked-up from her day program on 12/21/09. He stated he did not realize Client A's physician had not been notified of the injury and x-rays had not been obtained until the following day. The QMRP acknowledged the physician should have been notified and treatment obtained when Client A was unable to ambulate with a red, swollen, and painful ankle. The Department determined the facility failed to notify Client A's physician when Client A sustained an injury to her left ankle and was unable to ambulate. These violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 100000070 |
Sherwood Healthcare Center |
030012238 |
B |
18-May-16 |
CYVQ11 |
4663 |
H&S Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The following citation is written as a result of entity reported incident #CA00482003. Unannounced visits were made to the facility on 3/29/2016 and 4/8/2016 to investigate an allegation of abuse.The Department determined the facility failed to report an allegation of abuse within 24 hours as required, when Licensed Nurse (LN) 1 witnessed suspected sexual abuse of Patient B by Patient A on 3/26/2016 when Patient A touched Patient B's genital area. This violation potentially placed facility residents at risk for continued abuse. Patient A was an 85 year old admitted to the facility in early 2016 with diagnoses which included dementia (decline in mental ability) and cerebrovascular disease (limited or no blood flow to parts of the brain). Their Minimum Data Set (MDS, a standardized assessment tool), dated 2/24/2016, documented Patient A had a Brief Interview for Mental Status (BIMS - an assessment screening tool used to assess cognition) score of 3. This indicated severe cognitive impairment. Patient B was an 80 year old admitted to the facility in early 2016 with diagnoses which included dementia and spinal stenosis (narrowing of the open spaces in the spine putting pressure on the spinal cord). Their MDS dated 3/14/2016 documented Patient B had a BIMS score of 7. This indicated severe cognitive impairment. In an interview with Licensed Nurse (LN) 1 on 3/29/2016 at 3:05 p.m., LN 1 stated he saw Patient A's wheelchair was empty and found Patient A in Patient B's room between 8-9 p.m. on 3/26/2016.In concurrent interview and record review with LN 1 on 3/29/2016 at 3:30 p.m., Patient A's Nurse's Notes dated 3/26/2016 at 9 p.m., were reviewed and discussed. LN 1 verified he had written and signed the notes. LN 1 further stated the Nurses Notes were in reference to Patient A making sexual advances to Patient B. In a concurrent interview and clinical record on review with the Director of Nursing (DON) on 3/29/2016 at 3:40 p.m., Patient A's Nurses Notes dated 3/26/2016 at 9 p.m. were reviewed and discussed. The nurse's notes indicated Patient A was exhibiting "sexually explicit behavior." The DON stated LN 1 did not inform her of Patient A's "sexually explicit behavior" towards Patient B. In a concurrent telephone interview and clinical record review on 3/30/2016 at 3:12 p.m. with LN 1, (who was at the facility), Patient A's Nurse's Notes dated 3/26/2016 at 9 p.m. were reviewed and discussed. LN 1 stated the "sexual explicit behavior" he noted in the Nurse's Notes was in reference to Patient A having their left hand under the covers and on Patient B's private parts/groin area while Patient B was lying on their back in their own bed. LN 1 stated he did not notify the ombudsman because it was 10 p.m., the police because it was not a criminal act, the DON or the Administrator. LN 1 stated he was not aware of the facility's policy or protocol to report the incident. LN 1 stated he did not fill out the facility's form for reporting suspected dependent adult/elder abuse or notify the "Department" (California State Department of Public Health, Licensing and Recertification).In a concurrent interview and clinical record review on 4/8/2016 at 9:25 a.m. with the DON, Patient A's Nurse's Notes written by LN 1 dated 3/26/2016 at 9 p.m. documenting "sexually explicit behaviors" were discussed. The DON stated LN 1 was to fill out the facility's form as he was a mandated reporter and was to report the incident of alleged abuse to the DON or Administrator, and LN 1 did not do so. The DON stated the facility's form had not been filled out and an investigation of the alleged abuse did not occur. Review of an undated facility document titled Elder Abuse and Abuse Reporting specified, "It is the responsibility of the employees of [facility name] report any incident or suspected incident or suspected incident of neglect or resident abuse..." and "All employees must report any suspected abuse or incident of abuse to the Director of Nurses and/or Administrator." This document was signed and dated, 2/17/2016, by LN 1 under the statement, "I have read and understand the abuse policy:" Therefore, the Department determined the facility failed to report an allegation of abuse within 24 hours as required, when LN 1 witnessed suspected abuse of Patient B by Patient A on 3/26/2016 when Patient A touched Patient B's genital area. |
| 030000067 |
Sacramento Post-Acute |
030012928 |
A |
9-Feb-17 |
M1HO11 |
8497 |
F314 42 CFR 483.25(c) Treatment/Service 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 Department determined the facility failed to assess and monitor Resident 1's skin condition to prevent the formation of pressure sores.
Review of Resident 1's medical record, included a form titled Resident Admission Record, which revealed Resident 1 was admitted to the facility on XXXXXXX 14 with a tracheotomy (surgical opening on the neck to facilitate breathing) and diagnoses of quadriplegia (paralysis of all 4 extremities). Documentation on both, Skin Observation assessment and the Resident Progress Notes completed on admission by Licensed Nurse (LN1), dated 1/2/14, revealed Resident 1's skin as being "intact with no pressure ulcers (open wounds or skin breakdown), No hx [history] of pressure ulcers with no redness or soreness noted during skin assessment.
On 1/22/16, during an interview with the Director of Medical Records (DMR) at 3:45 p.m., she reviewed the medical record and confirmed that, during the first seven days of the resident's stay (January 2nd through 9th, 2014), documentation failed to show evidence the resident's skin condition was assessed or monitored for pressure ulcers by licensed nursing staff. There was no evidence any interventions were consistently provided in the Progress Notes from January 2nd through 8th, 2014, and the DMR concurred that there were no Care Plans initiated upon admission or thereafter that indicated Resident 1's skin condition was assessed, that the resident was at risk for pressure ulcers, or of any preventative measures to be provided to prevent skin breakdown.
On 8/3/2016, at 3 p.m., in an interview with LN2, she reviewed Resident 1's Care Plans, Observation Reports and Resident Progress Notes from January 2nd through 8th, 2014, and concurred that there were no Care Plans initiated upon admission or thereafter that indicated Resident 1's skin condition was assessed, that the resident was at risk for pressure ulcers, or of any preventative measures to be provided. LN2 further stated that, after knowing that the resident was a quadriplegic and could not turn on his own, "It should have been automatic [Resident 1 was paralyzed and therefore was at risk for pressure ulcers] for the nurses to routinely change the president's position every 2 hours and conduct periodic skin assessments."
Review of the clinical record of Resident 1 revealed the following 3 pressure ulcers were documented in the resident's Progress Notes within the first seven days of admission to the facility:
1. RIGHT BUTTOCKS - an entry, dated 1/8/14 at 3:11 a.m., indicated Resident 1 was observed by LN1 to have, "...an open area on bilateral (both right and left) buttocks, measuring 8 cm L (length) x (by) 4 cm W (wide) by 2 cm D (depth) (cm=centimeter-Units of measure)."
2. POSTERIOR (back side of) LEFT HEEL - on 1/9/14, an observation, documented at 5:28 p.m., indicated the development of a pressure ulcer on the resident's posterior left heel. The document titled, Pressure Ulcer Report, identified the wound as a Stage II pressure ulcer [partial thickness loss of the skin with a red moist wound base], measuring 4 x 4 cm, depth UTD [unable to determine], with light exudate [cells and fluid that have leaked out of blood vessels] of serosanguinous drainage [yellowish fluid leaking from the body or a wound].
3. LEFT BUTTOCK - on 1/9/14 at 4:54 p.m., an entry was made into the facility's Skin--Pressure Ulcer Report describing a Stage II pressure ulcer to the left buttock. This wound measured 4 L x 2 cm W x UTD.
Facility's Policy and Procedure titled, Pressure Ulcers/Skin Breakdown, last revised date, October 2010, indicated that, "The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores: for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition the nurse shall assess and document/report the following: ...Resident's mobility status."
Facility's Policy and Procedure titled, Prevention of Pressure Ulcers, last revised date, October 2010, indicated, "The facility should have a system/procedure to assure assessments are timely...Identify risk factors for pressure ulcer development... for a person in bed...Change position at least every two hours or more frequently if needed....Determine if resident needs a special mattress...Risk Factor - Bed Fast ...change position at least every two hours and more frequently if needed...Risk Factor - Immobility... When in bed, every attempt should be made to "float heels" [keep heels off of the bed] by placing a pillow from knee to ankle or with other devices as recommended ...For residents with risk factors, implement preventative measures as indicated... "
There was no documented evidence that the facility followed the policy and procedure on intervening and preventing the formation of pressure ulcers in Resident 1's care plans.
Subsequent documentation review of Resident 1's clinical record revealed the following documented additional assessments of his wounds on the form titled Skin-Pressure Ulcer Report:
1. RIGHT BUTTOCKS - An entry dated 1/9/14 at 13:12 (1:12 p.m.) indicated a Stage II Pressure Ulcer and the wound size was noted to be 8 cm L x 4 cm W and the depth of the wound was UTD. The document noted the wound was dark purple in color with some skin peeling off, irregular shaped edges, erythema (redness of the surrounding skin surface), no exudate, no drainage, and no odor.
An entry dated 1/16/14 at 13:07 (1:07 p.m.) indicated a Stage II Pressure Ulcer that now measured 10 cm L x 3 cm W and the depth was again noted as UTD. The note indicated that the wound now had light serosanguinous exudate on the edges, no signs and symptoms of infection, dark purple in color with some skin peeling off, irregularly shaped edges, wound area with redness, and no odor.
An entry dated 1/21/14 at 15:59 (3:59 p.m.) noted a Stage II Pressure Ulcer measuring .09cm L [sic] x2.08 cm W with the depth again noted to be UTD.
2. POSTERIOR LEFT HEEL - An entry dated 1/16/14 at 12:58 (12:58 p.m.) indicated a Stage II Pressure Ulcer measuring 4 cm x 3 cm, with a light serosanguinous exudate described as an open area.
All documented assessments were provided by the facility to the Department by the Administrator (ADMIN) on 4/26/16 at 12:30 p.m. There were no further documented assessments of this wound provided.
3. LEFT BUTTOCK - All documented assessments were provided by the facility to the Department by the Administrator (ADMIN) on 4/26/16 at 12:30 p.m. There were no further documented assessments of this wound provided.
On 1/23/14 Resident 1 was transferred to the General Acute Care Hospital (GACH). Review of Resident 1's clinical record from the GACH indicated staff there assessed the wounds on admission with the following notations in the document titled Wounds:
1. COCCYX (small bone at the base of the spine) - an entry dated 1/23/14 at 0900 (9a.m.) indicated an unstageable full thickness pressure ulcer, tunneled deep tissue wound, unable to get exact measurements.
2. HEEL LEFT - an entry dated 1/23/14 at 0832 (8:32 a.m.) indicated an unstageable necrotic (dead tissue) wound 3 cm in diameter.
3. RIGHT HIP - an entry dated 1/23/14 at 0900 (9 a.m.) indicated a Stage II pressure ulcer with a dressing in place.
4. LEFT FOOT - an entry dated 1/23/14 at 08:35 (8:35 a.m.) indicated an unstageable wound described as a "2 cm round blood blister to the sole of the foot."
The Department determined the facility failed to assess and monitor Resident 1's skin condition to prevent the formation of pressure sores.
These violations, separately or jointly, presented either (1) imminent danger that death or serious harm to the patients or residents of long-term health care facility would result there from or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result there from. |
| 100000097 |
Saylor Lane Healthcare Center |
030013081 |
B |
24-Mar-17 |
ONVX11 |
20146 |
Title 22 72321 Nursing Services - Patient with Infectious Diseases
(b) The facility shall adopt, observe and implement written infection control policies and procedures. These policies and procedures shall be reviewed at least annually and revised as necessary.
The following citation is written as a result of an investigation of complaint #CA00511986 which alleged that on 11/28/16 the facility had an outbreak of flu like symptoms and the facility was not doing anything to prevent other residents from getting ill which resulted in one death. Unannounced visits were made to the facility on 11/28/16 and 12/8/16 to investigate the allegation of a respiratory outbreak.
The Department determined the facility failed to recognize an outbreak of respiratory infection, implement meaningful measures to prevent the spread of the respiratory infection, and failed to report the outbreak to the Department as required. As a result of these failures, fifteen patients developed symptoms of respiratory infection (40% of the patients in the facility), four were hospitalized (Patient 3, Patient 5, Patient 12, and Patient 13), and three patients (Patient 3, Patient 5, and Patient 6) died after they developed respiratory symptoms.
Patient 3 was a XXXXXXX year old admitted to the facility in 2015 with diagnoses which included chronic kidney disease.
Review of the clinical record for Patient 3 included:
A physician's note, dated 11/25/16, which documented the patient had a "cough [for] 3 days".
A nurse's note, dated 11/25/16, which reflected the patient had a "cold/cough." The note indicated her O2 sat (oxygen saturation, the percentage of oxygen in the blood) was 94% without giving supplemental oxygen. Normal range is 95 to 100 percent. Ninety percent or lower is considered to be a low oxygen level.
A physician's order, dated 11/25/16, directed staff to start antibiotics and obtain a chest x-ray. Another 11/25/16 order was to start oxygen at 2 liters per minute as needed to keep the O2 sat over 90%.
A report of a chest x-ray completed on 11/26/16, indicated, "Results: There is increased density (usually due to fluid in the lung) at the right lung base."
A complete blood count (CBC) completed on 11/26/16, revealed the white blood cell (WBC) count was 25.5, normal range was defined on the report as 4-10. Elevated WBC's indicated infection or inflammation.
A Resident Transfer Form, dated 11/27/16, indicated the patient had "O2 sat 83% on 4 L [liters] [oxygen], Lethargic [sluggish], Labored breathing."
General Acute Care Hospital (GACH) clinical records for Patient 3 included: a chest x-ray, dated 11/27/16 at 7:50 a.m., indicated, "Findings . . .Thick linear band right lung base consistent with atelectasis [a partial collapse of the lung]."
A Physician Consultation report, dated 11/27/16, indicated Patient 3 was seen in the emergency room (ER) for "acute respiratory failure." (Acute respiratory failure occurs when fluid builds up in the air sacs in the lungs. When that happens, the lungs can't release oxygen into the blood. In turn, the organs can't get enough oxygen-rich blood to function.) The "History of Present Illness" included, "Normally, she is fully alert and oriented walking around . . .currently totally ill, so she cannot really give any kind of history." The physician wrote, ". . . I am concerned she may not survive hospitalization. We will focus on comfort measures alone." The GACH record indicated Patient 3 expired on XXXXXXX16 at 10:10 p.m., 14.5 hours after leaving the nursing home.
Patient 5 was most recently readmitted to the facility in early XXXXXXX 2016 with diagnoses which included cognitive decline.
Review of the clinical record for Patient 5 included:
A physician's order, dated 11/23/16, for Robitussin (medication to make coughs more productive) every four hours as needed.
A nurse's note, dated 11/23/16 at 10 a.m., which indicated Patient 5 was using oxygen at 2 liters per minute and had an O2 sat of 92%.
A nurse's note, dated 11/27/16 at 7:30 a.m., revealed, "Resident was experiencing [increased] Confusion, [decreased] O2 sat and twitching. O2 sat 88% on 4 L [liters] O2. Body twitching. Labored breathing. Unable to answer questions appropriately . . . resident was sent to ER."
The GACH records for Patient 5, dated 11/27/16, indicated in the Emergency Medicine - Provider Note, Patient 5 arrived in the emergency room at 7:51 a.m. on 11/27/16, and had a temperature of 103.2 degrees F (Fahrenheit) and a respiratory rate of 28 breaths per minute (normal range 12-20), Patient 5's pulse was 107 beats per minute (normal range 60-100), and the physician described her as "Ill appearing." A chest x-ray reflected, "minimal opacity [lack of transparency] at the right lung base." (Lung opacity is an indication of lung disease including pneumonia.) Patient 5's WBC level was "18.4" significantly elevated.
The "Hospitalist Discharge Summary," dated as completed 12/2/16, described Patient 5's final diagnoses as: "Hypoxemia [low oxygen levels in the blood] . . . Pneumonia of lower lobe due to infectious organism . . . Patient went into acute respiratory failure overnight . . . [family] . . . requested patient to be made comfort care and hospice was consulted today. Patient was placed on morphine [narcotic pain medication also helpful in controlling shortness of breath] drip which was changed to [morphine by mouth] prior to discharge to snf [skilled nursing facility] . . . Condition on Discharge: guarded . . . [Patient] is oriented to person, place and time. [Patient] appears distressed."
Review of an electronic health record note from Patient 5's primary care physician's office, dated 12/9/16, included, "Patients daughter called wanting to inform [doctor's name] that patient has passed away."
With the onset of Patient 5's cough on 11/23/16, the facility had 4 patients with coughs and new orders to treat their coughs.
During an observation on 11/28/16, started at 12:45 p.m., three Certified Nursing Assistants (CNAs) were observed wearing masks near the nurse's station. More than 10 patients were observed in the dining room for lunch.
In an interview with CNA 1 on 11/28/16 at 12:45 p.m., CNA 1 stated staff were wearing masks because, "Some people have a little cough."
In an interview with (Licensed Vocational Nurse) LVN 1 on 11/28/16 at 12:50 p.m., LVN 1 stated 4 patients "have a cough." She provided the names of 4 patients. LVN 1 stated chest x-rays had been done and those patients were all on an antibiotic.
During a tour of the facility on 11/28/16 started at 12:52 p.m., another patient was observed in bed resting with her eyes closed. She was wearing an oxygen cannula (tube) in her nostrils. Her roommate was not in the room and the bed was made.
During an observation and interview on 11/28/16 at 1 p.m., another patient was observed in her room and she stated, "I can't be in the dining room because I have a cough."
During an observation and interview on 11/28/16 at 1:03 p.m., another patient was heard coughing productively. The patient was alert and appropriate and stated she had a cough for 4 days. She had a roommate in her room.
During an observation and interview on 11/28/16 at 1:10 p.m., another patient was observed in her room and she was heard to have a productive cough. The patient stated, "I thought it was just a cold." She stated she had a chest x-ray and started antibiotics. She stated the cough and fever started 4 to 5 days earlier. She complained of a reduced appetite and stated the doctor saw her yesterday. She was observed to have 2 roommates.
During the tour, all patient rooms were observed and none of the rooms contained isolation supplies or any signage that indicated protective measures against the spread of infection had been initiated.
Review of a 24 Hour Report, dated 11/27/16, listed 2 patients who had been sent to the emergency room and 4 other patients who had been started on antibiotics for URI "[upper respiratory infection]." The report also noted Patient 3 had, "Passed away at hospital."
In an interview with the Director of Nurses (DON) on 11/28/16 at 1:15 p.m., the DON stated, "Whoever coughs or exhibits cold symptoms is kept in their room and we use Universal Precautions [the practice in medicine of avoiding direct contact with patients' bodily fluids, by means of the wearing of nonporous articles such as medical gloves]." The DON was asked what constituted an outbreak of symptoms to her; she stated, "More than 3 to 4 cases we consider an outbreak." The DON stated the outbreak had not been reported to local health officials or the Department, although it was to be done, "Immediately when more than 2 to 3 people had symptoms." She stated the outbreak started, "Sometime last week."
During an interview with the Director of Staff Development (DSD) on 11/28/16 at 2:15 p.m. the DSD stated an outbreak was, "three cases of the same virus or symptoms." The DSD stated she had not been at work over the weekend. The DSD stated she advised staff to keep an eye on patients, check their temperatures, and if more people or symptoms, report it to local health officials and the Department.
Review of the facility's policy titled, "Outbreak of Communicable Disease," dated as revised December 2009, directed, "Outbreaks of communicable diseases within the facility will be promptly identified and appropriately handled. An outbreak of most communicable diseases can be defined as one of the following . . . Occurrence of three (3 - 4) or more cases of the same infection over a specified period of time and in a defined area."
In an interview with the MD (Medical Doctor) on 11/29/16 at 4:15 p.m., the MD stated, "Until yesterday I wasn't aware [of the outbreak]." When asked how the MD would expect staff to protect residents the MD stated, "I should have been notified." The MD verified all patients in the sample were his patients.
Review of a letter to the Department, dated 11/28/16 and faxed at 4:40 p.m., by the Administrator, included: "This letter is to inform you of a potential outbreak at [facility name] of common cold symptoms. As of 11/28/16 there are six possible cases of URI [upper respiratory infection] where antibiotics were ordered by the physician. One of the six is positive for pneumonia . . .Three of the residents received a chest x-ray that came back clear."
In an interview with the Administrator on 12/8/16 at 3:40 p.m., the Administrator agreed the outbreak had occurred approximately 11/24/16. When asked if the facility had responded to the outbreak promptly, he stated, "No." He stated, "I should have been notified."
Review of another letter to the Department, dated 12/12/16 and faxed at 3:44 p.m., by the Administrator, included: "The most recent summary of the recent cough outbreak at [facility name] is attached." The attached summary, titled, "[facility name] Coughing Outbreak Summary 12/12/16" listed fifteen patients with symptoms of respiratory infection.
Patient 6 was a 90 year old most recently readmitted to the facility in early 2015 with diagnoses which included Alzheimer's disease (a disease that affects cognitive function and memory).
Review of the clinical record for Patient 6 included:
A chest x-ray, dated 11/26/16, which indicated, "Possible mild right middle lung consolidation."
A CBC, dated 11/26/16, which indicated the WBC was 15.9 (elevated above normal, usually indicative of an infection or inflammation.)
Nurses notes, dated 11/29/16, which indicated Patient 6 was unable to swallow foods, only thickened liquids.
A nurse's note, dated 11/29/16, which indicated hospice care was initiated.
Patient 6 expired XXXXXXX/16 at approximately 6 p.m., under hospice care.
One patient was most recently readmitted to the facility in XXXXXXX 2016 with diagnoses which included chronic lung disease.
Review of the clinical record for this patient included:
A nurses note, dated 11/25/16, which indicated, "has bad cough [and] yellow sputum . . ." Later the same day, another nurses note included, "Continues to cough up sputum."
A physician's order, dated 11/26/16, for antibiotics and cough medicine. Another order the same date was for a CBC.
A physician's order, dated 11/27/16, for a chest x-ray and a pertussis (whooping cough, a highly contagious respiratory tract infection) antibody test.
Results of the 11/27/16 CBC included white blood cells measured at the high end of normal range: 9.6.
A report of a chest x-ray, dated 11/28/16, concluded, "Possible early left lower lobe infiltrate [area of the lung filled by a liquid or solid mass]."
During an interview with the local public health nurse (LPHN) on 1/12/17 at 9 a.m., the LPHN stated this patient had tested positive for Respiratory Syncytial Virus (RSV), a common wintertime respiratory virus that affects persons of all ages and was the major cause of serious lower respiratory tract infections in young children. However, RSV was also an important pathogen in adults, particularly in the elderly, patients with chronic lung disease or those with impaired immunity.
Patient 12 was an 87 year old admitted to the facility on XXXXXXX16 with a fracture.
Review of Patient 12's GACH clinical record included:
An emergency physician's note, dated 12/5/16, "presents with worsening cough that began 3 weeks ago. Patient states that his cough is productive with yellow phlegm [sputum]. He also complains of associated shortness of breath . . . Symptoms are described as moderate in severity." The note referenced chest x-ray results, "left lower lobe pneumonia and is needing an increased amount of oxygen. White [blood cell] count is elevated. He is tachycardic [heart rate over 100]."
A CBC, dated 12/5/16, included a WBC of 15.1 (normal range was 4 to 11).
The discharge Summary, dated 12/9/16, listed his diagnosis as "Pneumonia of left lower lobe due to infectious organism."
Patient 13 was admitted to the facility XXXXXXX/16 with diagnoses which included heart disease.
Review of the GACH clinical record for Patient 13 included:
An emergency physician's note, dated 12/5/16, indicated, "78 year old . . . with a history of . . . COPD [chronic obstructive lung disease] . . .presents with worsening shortness of breath tonight . . ..has had a productive cough with yellow and green sputum for the past few days . . .febrile [with fever] at 103.1 degrees Fahrenheit. She has room air oxygen saturations of 83% . . ."
A Hospitalist History and Physical (H&P), dated 12/5/16, which included, under, "PLAN: . . . Patient is actually more lethargic now . . .admitting the patient to ICU [Intensive Care Unit]." The same note, under Assessment & Plan: revealed, "respiratory failure likely secondary to . . . [pneumonia].
In an interview with the GACH Clinical Coordinator for Quality (CCQ) on 12/12/16 at 9:30 a.m., the CCQ stated Patient 13 had been in intensive care on a ventilator [breathing machine] and was still in the hospital on 12/12/16.
In an observation at the Administrator's office on 11/28/16 at 3 p.m., the Dietary Manager (DM) was observed to have a productive cough and heard saying to the Administrator, "I've had this cough for a week." The DM was observed to move her mask below her nose and to partly remove it.
In an interview with the DM on 11/28/16 at 3 p.m., the DM stated, "I've been off 4 days. I had it [cough] 2 days last week, but covered up all the time."
In an observation of the kitchen on 11/28/16 at 3:10 p.m., the kitchen where food was prepared for facility patients was observed to be a long, narrow, open room with 2 people working in it. A desk was observed in a narrow alcove near the hand washing sink, without walls or a door. A staff member was observed walking past the desk chair to get to the dry storage area beyond the desk, then returning to the food preparation area.
In an interview with Cook 1 on 11/28/16 at 3:10 p.m., Cook 1 was asked about the DM's cough. Cook 1 stated, "It's been about a week . . .[DM] worked Monday, Tuesday, and Wednesday last week." The Cook further stated Cook 2 had been sent home early that day (11/28/16), due to an illness. Cook 1 verified the DM's desk was situated on the edge of the kitchen without any walls or doors. Some diseases are spread via droplets when people cough.
In an interview with the Administrator on 11/28/16 at 3:05 p.m., he stated the DM did not handle food. He stated, "If a dietary aide or cook is sick, we send them home."
Review of the facility's policy titled, "Outbreak of Communicable Disease," dated as revised December 2009, directed, "Symptomatic residents and employees are to be considered potentially infected and will be assessed for appropriate actions. The Administrator will be responsible for: Telephoning a report to the health department; Restricting admissions to the facility as indicated or as authorized by the health department/Medical Director; Submitting periodic progress reports to the health department, as requested; Calling emergency meetings of the Infection Control Committee; Discontinuing group activities, as indicated; Limiting visitors if indicated . . . Director of Nursing Services will be responsible for: Receiving surveillance information and tabulating data; . . . Notifying the Medical Director . . . nursing staff will be responsible for: Notifying the Director of Nursing Services of symptomatic residents; Providing infection surveillance data in a timely manner; Obtaining laboratory specimens; . . . Initiating isolation precautions as directed or as necessary; and Confining symptomatic residents to their rooms as much as feasible . . ."
Review of the "Recommendations for the Prevention and Control of Influenza California Long-Term Facilities, dated as revised 12/2011, directed: "Influenza, other respiratory viruses, and some bacteria cause similar illnesses, particularly elderly long-term care facility (LTCF) residents . . . In most infected persons the symptoms progressively resolve after 3 to 7 days . . . Complications, especially in unvaccinated long-term care residents, include pneumonia, worsening of chronic health conditions, and dehydration . . . Influenza . . . virus is primarily spread by viral particles coming into contact with the respiratory tract after they are expelled short distances into the air (approximately 6 feet or less) when an infected person coughs or sneezes (droplet transmission)."
In an interview with LVN 1 on 12/8/16 at 2 p.m., LVN 1 verified she had worked the weekend after 2 residents began coughing. LVN 1 stated on Sunday 11/27/16 at the start of the day shift 2 patients, Patient 3 and Patient 5, were sent out to the emergency room. LVN 1 stated she had not notified the Director of Nurses about the number of patients who were symptomatic over the weekend, and had not isolated the patients with coughs.
During an interview on 12/8/16 at 2:45 p.m., the Director of Staff Development (DSD) stated that prior to Monday 11/28/16, patients with coughs were encouraged to stay in their rooms. The DSD stated, "Nobody was on isolation." The DSD stated the facility had not suspended group activities or community dining, and the facility was still admitting new patients.
In an interview with the DON on 12/8/16 at 3:40 p.m., the DON stated, "I think we did what we were supposed to do. The best we can do is isolating the virus. Some patients wore masks, roommates were 3-5 feet distance [from each other]."
Therefore, the Department determined the facility failed to recognize an outbreak of respiratory infection, implement meaningful measures to prevent the spread of the respiratory infection, and failed to report the outbreak to the Department as required. As a result of these failures, fifteen patients developed symptoms of respiratory infection (40% of the patients in the facility), four were hospitalized (Patient 3, Patient 5, Patient 12, and Patient 13), and three patients (Patient 3, Patient 5, and Patient 6) died after they developed respiratory symptoms.
These failures had a direct or immediate relationship to the health, safety, or security of patients. |
| 100000097 |
Saylor Lane Healthcare Center |
030013459 |
B |
30-Aug-17 |
HFC111 |
7025 |
F206 483.15 (e)(1) Policy to Permit Readmission Beyond Bed-Hold
(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.
(i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident-
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services.
(ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.
(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.
The following citation was written as a result of complaint #CA00518158. An unannounced visit was made to the facility on 1/23/17 to investigate an allegation of refusal to readmit.
The Department determined the facility failed to:
Readmit Resident 1 after an emergency department visit and hospitalization at the General Acute Care Hospital (GACH).
This failure had the potential to cause emotional distress and/or harm to Resident 1, who was a long term resident of the facility.
Resident 1 was admitted to the facility with multiple diagnoses. Her Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had moderate impairment of her cognition (the activities of thinking, understanding, learning, and remembering).
During initial tour observations of the facility on 1/23/17 starting at 9:17 a.m., Resident 1 was not found residing in the facility.
Review of the facility document titled Resident Roster, dated 1/23/17, indicated Resident 1 was not present in the facility.
Review of the document titled "Resident Transfer Form", dated 12/21/16, indicated Resident 1 was sent out to the GACH because she needed evaluation and treatment. The facility indicated they were "unable to provide care needed."
During an interview with the Social Services Director on 1/23/17 at 10:08 a.m., she said, "She went out 12/21/16 [to the GACH] ...We did not give her a verbal or written bed hold..."
Review of the GACH Online Referral for Resident 1, dated 1/5/17 at 3:55 p.m., indicated "This patient is from your facility and once medically stable, if she does not DC [discharge] to a [a different] facility first, will return to your facility since she has been at your facility for long term placement..." The SSD responded on the same form on 1/6/17 at 9:37 a.m., "When resident went out I did not put her on a bed hold, and I have no long term beds." Resident 1 was medically cleared to leave the GACH on 1/13/17. Facility responded on 1/13/17 at 2:09 p.m. "No, unable to accept patient...Unable to meet her needs..."
Review of the acute care Consult Progress Note, dated 1/13/17, indicated, "Much calmer...cooperation with [name of acute care hospital] staff has been fair since delirium resolved 1/6/17...taking most scheduled meds [medications]. Appears at baseline..."
During a telephone interview with the Licensed Clinical Social Worker/Case Manager at the GACH on 1/31/17 at 11:35 a.m., she/he said, "[Resident 1] is stable...She could go back to the facility...I spoke to [SSD] and she said they [facility] would not take her back..."
A voice mail was left for the Department by the facility Administrator on 2/7/17 at 9:34 a.m. and said Resident 1 was readmitted to the facility 2/6/17.
The facility document titled "Resident Roster" was reviewed from 1/23/17 through 2/6/17. There were multiple empty beds in semi-private rooms on a daily basis at the facility for those dates. Resident 1 was not on the Resident Roster from 1/13/17 through 2/5/17. It was 24 days from the time Resident 1 was cleared by the GACH to return on 1/13/17 until she was readmitted on 2/6/17.
Review of the facility policy and procedure titled "Holding Bed Space", dated December 2006, indicated "...8. A Medicaid resident ... whose hospitalization or therapeutic leave exceeds the bed-hold period established by the State Medicaid Plan will be readmitted when a bed in a semi-private room becomes available."
During a concurrent record review and interview with SSD on 4/7/17 at 2:45 p.m. she verified Resident 1 was not readmitted to the first available semi private room when the GACH was ready to discharge her.
Therefore, the Department determined the facility failed to:
Readmit Resident 1 after an emergency department visit and hospitalization at the General Acute Care Hospital (GACH).
This violation had a direct or immediate relationship to the health, safety or security of Long Term Care patients or residents. |
| 040000898 |
SAFE HARBOR RESIDENTIAL SERVICES-DOUTY |
040010979 |
B |
03-Sep-14 |
O0PC11 |
8274 |
CLASS B CITATION - STAFF TREATMENT OF CLIENTS W149 483.420 (d)(1) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect or abuse of the client. On 8/18/14 at 1:40 p.m., an unannounced visit was made to the facility to investigate an entity reported event regarding medication error. The facility failed to prevent neglect when: 1. Non-licensed staff had not administered a physician prescribed dose of Valium (a long-acting medication for anxiety) prior to Client A's laboratory (lab) draw (blood taken for testing), and administered Ativan (a short-acting medication for anxiety) without a physician's order.2. The Licensed Vocational Nurse (LVN) and non-licensed staff did not ensure the administration of a physician prescribed evening dose of Ativan, and administered Valium as a substitute medication to Client A without a physician's order. The non-licensed staff, following instructions from the LVN, administered Valium instead of Ativan [which had been ordered by the physician] to Client A. Valium 5.0 milligrams (mg) had been ordered by the physician to be administered before a lab draw. The staff gave Valium 10 mg, unrelated to a lab draw which resulted in a dose that was two times the dose.This left Client A not monitored for respiratory depression from the high dose of Valium administered.Client A was a 60 year old, admitted to the facility on 11/13, with diagnoses that included epilepsy (brain disorder where a person has repeated seizures) and cerebral palsy (affect body movement and muscle coordination). Client A followed simple commands, could not speak in sentences, and had a history of agitation with eye contact. Client A's physician's order dated 7/14, indicated Valium 5 mg one tablet was to be given 30 minutes prior to a lab draw for sedation. Client A's physician order dated 7/14, indicated Ativan 3 mg was to be administered at hour of sleep each day. Client A's Medication Administration Record indicated the Ativan was to be administered at the facility-designated time of 8 p.m.1. On 8/18/14 at 2:35 p.m., the Facility Manager (FM) stated on 7/30/14, she instructed Direct Care Staff (DCS) to administer Ativan 3 mg instead of the physician prescribed Valium 5 mg to Client A, prior to a 4 p.m. lab draw. The FM stated she knew Valium 5 mg should have been administered per physician's order; but, had decided, based on the fact Ativan worked well to calm Client A during a previous emergency room visit. On 8/18/14 at 4:05 p.m., DCS stated on 7/30/14, the FM directed her to administer to Client A, Ativan 3 mg instead of the prescribed Valium 5 mg before a lab draw. DCS stated she read in Client A's clinical record under "nursing instructions" to give Valium 5 mg, but had not questioned the FM (her direct supervisor). DCS stated on 7/30/14 between 3:00 and 3:30 p.m., she administered Ativan 3 mg to Client A, prior to a lab draw.2. On 8/18/14 at 2:40 p.m., the FM stated DCS realized she made a mistake (on 7/30/14) when she gave Ativan 3 mg (designated for 8 p.m.) instead of the physician prescribed Valium 5 mg, to Client A prior to a lab draw.On 8/18/14 at 3:35 p.m., the FM stated she called the Administrator (Admin) about the medication error on 7/30/14 (that the 8 p.m. Ativan 3 mg was administered at 3-3:30 p.m. instead of the prescribed Valium 5 mg). The FM stated the Admin instructed the FM to inform the LVN, who in turn directed DCS to administer the Valium at 8 p.m. On 8/19/14 at 11:50 a.m., the Admin confirmed on 7/30/14 at 3:30 p.m., she instructed the FM to tell the LVN to direct DCS to give Valium 5 mg at 8 p.m., since Client A had not received Valium prior to the lab draw. The Admin stated there was no physician's order obtained to give Valium 5 mg at 8 p.m. [or any other time]. The Admin stated, "I made the call (decision)...," not the physician. On 8/19/14 at 2:35 p.m., the LVN stated (on 7/30/14) she was instructed by the FM, that the Admin wanted the LVN to direct DCS to give Valium. The LVN stated she told the DCS to "Give this Valium (a bottle containing two tablets of Valium [5 mg/tablet]), not right then, give it at 8 p.m." The LVN stated she knew about Client A's physician order for Valium 5 mg to be administered before a lab draw, not for Valium 10 mg to be administered at 8 p.m. The LVN stated she "should have double checked (for a physician's order for the Valium to be administered at 8 p.m.)... I was doing what I was instructed...I don't know why I did not question it." The LVN did not check for a physician's order, but took direction from non-licensed staff (the FM and the Admin).On 8/18/14 at 4:05 p.m., DCS stated on 7/30/14 at 5:30 p.m., the LVN informed DCS that the physician "switched" the medications (Ativan and Valium), and instructed DCS to give 10 mg of Valium to Client A at bedtime (8 p.m.). DCS stated on 7/30/14 at 8 p.m., she administered Valium two tablets (total of 10 mg).Client A's Nurse's Progress Notes dated 7/30/14 and 7/31/14, indicated the LVN had not contacted the physician or the RNs. The Progress Notes had no indication the staff had monitored Client A for potential respiratory depression (a decrease of breathing rate and depth) after the two medication errors had occurred.Client A' s Nurse's Progress Notes dated 8/1/14, RN 2 documented "[physician] was called (about the Valium 10 mg administered on 7/30/14 at 8 p.m.) and his main concern was respiratory depression..." Mosby's 2013 NURSING DRUG REFERENCE on "diazepam (Valium)" in the section "Precautions: [with] ...geriatric patients (55 years old and up)..." in the section "DOSAGE AND ROUTES...Geriatric: [by mouth] 1-2 mg daily-[twice a day], increase slowly as needed"...in the section "SIDE EFFECTS...[RESPIRATORY]: Respiratory depression (bold in red = life threatening)."On 8/19/14 at 1:50 p.m., during a concurrent interview with RN 2, and clinical record review, RN 2 stated she did not know about the Ativan and the Valium errors until 8/1/14, two days after the errors.On 8/20/14 at 1:50 p.m., RN 1 stated she found out about how the Ativan was administered for a lab draw on 8/1/14, two days later. RN 1 stated she found out about the Valium error (Valium 10 mg administered at 8 p.m. with no physician's order) on 8/18/14, 20 days later.Client A's Nurse's Progress Notes dated 8/1/14, indicated RN 2 notified the physician on 8/1/14 about the two medication errors of 7/30/14 (two days after the errors were made).The facility's policy and procedure titled, "Abuse, Neglect and Exploitation of Clients by Staff, including Corporal Punishment" dated 2010, indicated, "Neglect: Any situation in which the staff does not carry out assigned duties or responsibilities which in turn affect the health, safety or well being of a client..." The facility's policy and procedure titled, "Administration of Medications and Treatments" dated 2004, indicated, "1. Medications or treatments will not be given except on the order of a person lawfully authorized to give such an order. 2. Medications and treatments will be administered as prescribed and will be recorded in client records as ordered. Recording will include... time, strength, and dosage of the medication...10. Medication error report procedure is as follows: the nurse is called as soon as possible after discovery of a medication error. She will advise the staff how to proceed..." The facility failed to implement their policy on neglect and medication administration when: 1. The LVN and non-licensed staff did not carry out their assigned duties or responsibilities to obtain and follow physician's orders for two medications for Client A.2. The LVN and non-licensed staff decided to administer an anti-anxiety medication not ordered by the physician to Client A, and gave a dose that could have been toxic, potentially causing respiratory depression. The non-licensed staff failed to notify the RNs immediately about the two medication errors and the LVN failed to notify the physician and the RNs immediately about the two medication errors, placing Client A at potential harm for respiratory depression and other adverse effects. These violations placed Client A at potential for harm to "health, well being, and safety" and constitutes a B Citation. |
| 040001120 |
SIERRA HOUSE |
040012146 |
A |
24-Mar-16 |
UY6V11 |
6434 |
Class 'A' Citation - Program Implementation 483.440 (d)(3) Except for these facets of the individual program plan (IPP) that must be implemented only by licensed personnel, each client's individual program plan must be implemented by all staff who work with the client, including professional, paraprofessional and nonprofessional staff. The facility failed to implement Client A's IPP when they failed to follow physician orders to use the gait belt (used to transfer people from one position to another or while ambulating) during transfer for Client A which resulted in a fall and a fractured left femur (large thigh bone).Client A's face sheet indicated he was admitted to the facility on 2/19/13 with diagnoses including osteoarthritis (degenerative joint disease). Review of Client A's "Quarterly RN (registered nurse) Assessment" dated 10/22/15, indicated, "Prior to admission he had a decline in functioning with increasing problems with falls, pain and had two fractures..." The document indicatedClientA complained of lower extremity weakness and could bear weight with much effort and stand by assistance. Client A was non-ambulatory.Review of the Acute Hospital Emergency Department (ED) record, dated 11/7/15, titled, "Discharge Summary," the record indicated, Client A was taken to the ED by ambulance with left thigh swelling, onset 11/6/15. The document indicated Client A had a fall while being transferred from the wheelchair to a stationary chair at the facility. The document indicated a potential medical diagnosis of a fractured femur. Client A was medicated with 1 milligram of Hydromorphone [Dilaudid] (narcotic pain reliever used to treat moderate to severe pain), intravenously for pain. Client A was admitted into the hospital from the ED for surgical repair of the fractured left femur. The Operative/Procedure Report dated 11/08/15, indicated...."Surgical management is recommended to stabilize the fracture." Client A was an inpatient at the Acute Hospital from 11/7/15 through 11/11/15 and required Dilaudid, Morphine, (narcotic pain reliever used to treat moderate to severe pain), Fentanyl (powerful synthetic opiate analgesic used to treat severe pain or pain after surgery), Hydrocodone/Acetaminophen (Norco-narcotic and [Tylenol] non-narcotic pain reliever used to relieve moderate to severe pain) as a result of the left femur fracture. He was discharged to a rehabilitation facility for therapeutic recovery. The Rehabilitation Facility's document titled, History and Physical dated 11/12/15, indicated, Client A required "... An intensive rehabilitation program...PRESENT MEDICATIONS...Norco...for pain... PLAN... Patient will need 24-hour rehab (rehabilitation) nursing for wound care, ADL (activities of daily living) assistance, pain management, poly pharmacy (use of four or more medications by a patient)... For mobility and self-care- physical and occupational therapy... ESTIMATED LENGTH OF STAY 8 to 16 days..." During a review of the facility's document, titled, "INCIDENT INVESTIGATION," dated 11/9/15, the form contained documentation on 11/6/15, "... When [Client A] was transferring to bed, he stood from wheelchair to walker and lost his balance causing him to fall backwards into the chair..." The report indicated on 11/7/15 the Licensed Vocational Nurse (LVN) clarified this incident with Direct Care Staff (DCS)3 and DCS4 and determined, "... When [Client A] fell back into the chair the chair tilted forward slightly and [Client A] fell to the floor... it is clear this is likely where the injury occurred..." During review of Client A's Health Care Provider (HCP) Consultation and Progress Note dated 10/28/15, contained a physician's order "...Requires use of gait belt for transfers for safety..." On 11/25/15 at 9:35 a.m., during an interview with DCS 1, when asked if Client A had a gait belt for transferring, DCS 1 stated when Client A had been transferred the gait belt was not used to assist with the transfer.On 11/25/15 at 10 a.m., during an interview, DCS 2 stated she was never trained on how to transfer Client A, and when she did assist Client A with transfer the client told her what to do and where to stand during the transfer.On 11/25/15 at 2:01 p.m., during an interview, DCS 3 stated on the day of the fall she assisted Client A up from the wheelchair. DCS 3 stated she lifted Client A up from the buttocks, while at the same time Client A pulled himself up to the walker. DCS 3 stated this procedure was how she usually assisted Client A. On 12/8/15 at 4:28 p.m., during an interview, the LVN stated the gait belt was located in Client A's room and stated the gait belt hadnot been used by staff to perform his transfer. The LVN stated she had not received training on how to transfer Client A. The facility's undated "JOB DESCRIPTION LICENSED VOCATIONAL NURSE" document indicated, "...ESSENTIAL JOB FUNCTIONS: ... The LVN is responsible to assist and supervise the DDA's (Developmentally Disabled Attendant - same as Direct Care Staff) in providing therapeutic treatments. These may include... transfer skills.... " On 12/9/15 at 10:25 a.m., during an interview and concurrent record review with the Registered Nurse/Qualified Intellectual Disabilities Professional (RN/QIDP), the QIDP stated staff were not using the gait belt to transfer Client A prior to Client A's fall and injury.The facility's policy titled, "GENERAL SAFETY GUIDELINES AND CLIENT TRANSFER GUIDELINES," dated 5/1/14, indicated, "Purpose: To create a safe environment for all clients. POLICY: ... 18. Use gait belt... and other assistive devices for transferring when ordered... " The facility failed to implement Client A's IPP when they failed to follow physician orders to use the gait belt during transfer for Client A which resulted in a fall and a fractured left femur which required hospitalization, surgery and pain management from 11/7/15 to11/11/15 (4 days)andsubsequent transfer to a rehabilitation facility from 11/11/15 to 11/25/15 (14 days) for 24-hour rehabilitation nursing which included wound care, Activities of Daily Living assistance, pain management with the use of multiple pain medications, therapy for mobility and self-care 24 hours per day. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and therefore constitutes a Class 'A' Citation. |
| 040000037 |
SIERRA VISTA HEALTHCARE |
040012291 |
B |
25-May-16 |
REHO11 |
7845 |
CLASS B CITATION-ABUSE CFR 483.13(c), F226 The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, an misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. During an investigation of Entity Reported Incident (ERI) CA00463683, the Department determined the facility failed to implement its Resident Trust Fund policies and procedures and failed to protect 2 of 7 sampled residents (Resident 1 and Resident 2), from misappropriation of personal funds. This failure resulted in the successful unlawful withdrawal of funds from Resident 2's trust account, and a second unsuccessful attempt to withdraw from Resident 1's account. It placed all residents with trust fund accounts at risk for financial abuse and misappropriation of personal funds. 1. Review of ERI dated 10/29/2015 at 11:25 a.m., indicated CDPH received telephone notification from the facility regarding allegations of resident financial abuse, which read, "R 2 [Resident 2] passed away in April 2015....R 2's trust account with the facility was closed out on 9/23/15...$465 on R 2's residence trust banking account was cashed by someone that by name, no one knows or ever heard of..." In an interview with the Director of Social Services (DSS), on 11/12/2015 at 12 p.m., she stated Resident 2 expired in March 2015. She further stated the facility was informed by authorities of an unauthorized withdrawal of funds from her trust fund in the amount of $465. In an interview with the Administrator (ADM) on 11/12/2015 at 12:15 p.m., he stated during the facility investigation, he discovered an unauthorized withdrawal from Resident 2's trust account dated 9/23/2015, in the amount of $465. He further stated the Trust Account check was made payable to a person not known to the facility. In a second interview on 11/12/2015 at 1:45 p.m., the ADM stated it had been facility practice for the Director of Nursing (DON) or the DSS to sign checks on resident trust accounts. He further stated when the facility conducted its investigation several deficiencies in practice had been identified. Resident 2's clinical record indicated her Responsible Party was the [local] Public Guardian (PG) office. Review of Resident 2's "Trust Fund Authorization" document, dated 5/20/2013, indicated it was not current to Resident 2's change of status to PG responsibility. During a phone interview on 12/9/2015 at 1:55 p.m., the deputy PG stated the PG office assumed Conservatorship (court appointed) responsibility for Resident 2 on 6/7/2013. Facility Trust account balance sheets dated 3/31/2015 through 8/31/2015, listed Resident 2 as a client, with a balance of $465.07. Review of the facility bank check #4197, dated 10/28/2015, indicated it was made payable in the amount of $465.07 to "Estate of [Resident 2]." Under for, the check indicated "Close Trust Account." The check was signed by one signer, the DSS. Review of the facility document , "Resident Trust Fund Policies/Procedures,? revised October 2010, indicated, "If a resident chooses to establish a resident trust fund in his/her name, the resident, agent, or legal representative must authorize the facility to do so by signing the Resident Trust Fund Authorization form....No monies for any resident are to be held in trust by the facility without a signed authorization on file...Under Closing Resident Trust Accounts it indicated, "Upon expiration or discharge of a resident, funds held in the Resident Trust Account must be refunded to the individual or appropriate agency within the time frames as identified in Federal and State specific regulations. In the event of expiration time frame is generally 30 days...Verify time frames specific to per your state regulations. Under Authorized Signers it indicated, "...The following cannot be a signer on the Resident Trust Account; Social Service...All checks written on the Resident Trust Fund account must be signed by two (2) authorized check signers." Review of the facility policy and procedure, "Abuse Prevention" dated 3/2010, indicated under Policy, "Residents must not be subjected to abuse by anyone..." Under Misappropriation of resident property it indicated, "the deliberate ...use of a resident's belongings or money without the resident's consent." 2. Review of ERI dated 10/29/2015 at 11:25 a.m., the ERI indicated the facility notified CDPH regarding allegations of resident financial abuse, which read, "....On R 1, staff says there was an attempt to cash a personal check from her personal bank account for $5,526...reported from the bank...on 10/14/2015." In an interview on 11/12/2015 at 12 p.m., the DON stated he and the DSS were authorized signers for the Resident Trust Accounts. He further stated when the facility investigated, Resident 1 had been asked to sign a blank check, and did so. The check was then made payable to an unknown party in the amount of $5,226, and taken to a local bank in an attempt to cash the check. In an interview on 11/12/2015 at 12:10 p.m., the DSS stated the facility was notified by Adult Protective Services (APS) of an attempt to withdraw funds from Resident 1's checking account using her personal check. The DSS stated the facility held her checkbook in trust, and it was stored with the Business Office Manager (BOM) 1. Resident 1's clinical record indicated Resident 1 was admitted to the facility on 7/2/2012. Her current diagnoses included heart failure and dementia. Review of Resident 1's most recent Resident Assessment Instrument (RAI-an assessment of resident functional ability) dated 9/16/2015, indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated Res 1 had few cognitive deficits in recall and orientation. In an interview on 11/12/2015 at 3:50 p.m., Resident 1 stated she recalled being asked to sign a blank check, but was unable to recall who asked her to do so. She stated when she was informed of the unauthorized attempt to cash her personal check, she stated, "It was hard for me to sleep...nobody is supposed to do that....I couldn't understand." When asked if she had signed a document giving the facility permission to hold her checkbook in trust, she stated, "I did, and then I reneged...about a year later," and stated she informed the facility of her decision. Facility Trust Account balance statements dated 3/31/2015 through 8/31/2015, indicated Resident 1 was not listed on the facility's trust accounts. In an interview on 12/9/2015 at 2:20 p.m., the ADM was asked if facility staff requested Resident 1 sign a blank personal check, he stated, "That's true." Resident 1's written trust fund authorization was requested. The ADM was unable to produce documentation of written authorization. Review of the facility document, "Resident Trust Fund Policies/Procedures,? revised October 2010, indicated, "....No monies for any resident are to be held in trust by the facility without a signed authorization on file. Under Disbursements it indicated, "It is the responsibility of the facility to protect and provide proper documentation on all disbursements from the trust account...There are to be no blank checks signed by the facility." This failure to follow policy and procedure for resident trust accounts resulted in the successful unlawful withdrawal of funds from Resident 2's trust account, and a second unsuccessful attempt to withdraw from Resident 1's account. This violation presented a substantial probability of continued successful withdrawals against resident trust accounts and imminent danger serious financial harm would result, and therefore constitutes a Class B citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012397 |
B |
27-Jul-16 |
W2Y811 |
10336 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 1 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 1 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 1. As a result of these failures, Resident 1 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 1's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 1's clinical record titled, "Face Sheet" indicated Resident 1 was a 75 year old with diagnoses that included Schizoaffective Disorder (mental disorder including abnormal perception of reality and mood disorder), Altered Mental Status (disruption in how the brain works), and Heart Failure. Resident 1 was not able to manage her own affairs and had an appointed guardian. Resident 1's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $1,278.18. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15 indicated a total of 57 residents' monies were in the trust account, including Resident 1. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 1 and her Guardian, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 1's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 1 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15 indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 1, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 1's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 1's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 1's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012400 |
B |
27-Jul-16 |
W2Y811 |
10164 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 2 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 2 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 2. As a result of these failures, Resident 2 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 2's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 2's clinical record titled, "Face Sheet" indicated Resident 2 was a 57 year old with no specified diagnosis on the face sheet. Resident 2 had a friend that acted as the Responsible Party (RP) in his behalf. Resident 2's facility generated "Trust Statement," dated 2/28/15, indicated a closing balance of $0.00. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 2. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 2 and his RP, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 2's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 2 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank document titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank document titled, "Deposits and other Credits," indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 2, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 2's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 2's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 2's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012401 |
B |
27-Jul-16 |
W2Y811 |
10279 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 3 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 3 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 3. As a result of these failures, Resident 3 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 3's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 3's clinical record titled, "Face Sheet" indicated Resident 3 was a 67 year old with diagnoses that included Hemiplegia (paralysis of one side of the body), and Paralytic Syndrome (complete loss of strength in an affected limb or muscle group). Resident 3 had a Responsible Party who acted on his behalf. Resident 3's facility generated "Trust Statement," dated 10/31/15, indicated a closing balance of $0.00. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 3. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 3 and his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 3's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 3 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits," indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 3," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 3, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 3's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 3's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 3's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012402 |
B |
27-Jul-16 |
W2Y811 |
10411 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 4 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 4 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 4. As a result of these failures, Resident 4 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 4's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 4's clinical record titled, "Face Sheet" indicated Resident was a 48 year old with diagnoses that included 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), and Unspecified Psychosis (perception and understanding of reality are severely impaired). Resident 4 had a Responsible Party who acted on his behalf. Resident 4's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $5.00. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 4. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 4 and his Responsible Party were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 4's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 4 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1" dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 4, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 4's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 4's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 4's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012403 |
B |
27-Jul-16 |
W2Y811 |
10288 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 5 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 5 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 5. As a result of these failures, Resident 5 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 5's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 5's clinical record titled, "Face Sheet" indicated Resident 5 was a 57 year old with diagnoses that included Major depressive Disorder (mental illnesses characterized by a profound and persistent feeling of sadness) and Anxiety Disorder (fear, worries and distress). Resident 5 had a Responsible Party who acted on her behalf. Resident 5's facility generated "Trust Statement," dated 10/31/15, indicated a closing balance of $0.00. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 5. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 5 and her Responsible Party were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 5's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 5 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank documents titled, "Resident Trust Account 1" dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 5, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 5's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 5's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 5's, health safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012404 |
B |
27-Jul-16 |
W2Y811 |
10326 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 6 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 6 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 6. As a result of these failures, Resident 6 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 6's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 6's clinical record titled, "Face Sheet" indicated Resident 6 was a 57 year old with diagnoses that included Chronic Kidney Disease (kidney damage that reduces the functioning of the kidney), and Cerebrovascular Disease (blood flow to the brain is damaged by blockage or rupture of an artery to the brain). Resident 6 was responsible for his own medical and business affairs. Resident 6's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $2.84. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 6. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 6, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 6's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 6 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank documents titled, "Resident Trust Account 1" dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 6, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 6's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 6's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 6's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012405 |
B |
27-Jul-16 |
W2Y811 |
10377 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 7 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 7 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 7. As a result of these failures, Resident 7 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 7's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 7's clinical record titled, "Face Sheet" indicated Resident 7 was a 62 year old with diagnoses that included Schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior) and Bipolar Disorder (a mental disorder marked by alternating periods of elation and depression). Resident 7 was not able to manage her own affairs and had an appointed guardian. Review of Resident 7's "Trust Statement," dated 1/31/16, indicated a closing balance of $45.33. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 7. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 7 and her Guardian, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 7's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 7 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1" dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 7, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 7's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 7's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 7's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012406 |
B |
27-Jul-16 |
W2Y811 |
10519 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 8 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 8 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 8. As a result of these failures, Resident 8 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 8's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 8's clinical record titled, "Face Sheet" indicated Resident 8 was a 59 year old with diagnoses that included Chronic Kidney Disease(kidneys are damaged and not functioning properly), Cerebral Infarction (area of the brain damaged from lack of blood supply), Complete Traumatic Amputation (the removal of a limb by trauma, medical illness, or surgery), Blindness in both eyes, Psychosis (severe mental disorder causing loss of contact with reality), and Anxiety. Resident 8 had a family member who was her Responsible Party who acted on her behalf. Resident 8's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $63.83. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 8. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 8 and her Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 8's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 8 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1" dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 8, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 8's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 8's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 8's health, safety or security, or therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012407 |
B |
27-Jul-16 |
W2Y811 |
10693 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 9 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and is used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 9 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 9. As a result of these failures, Resident 9 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 9's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 9's clinical record titled, "Face Sheet" indicated Resident 9 was a 47 year old with diagnoses that included Major Depressive Disorder (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period), Chronic Embolism and Thrombosis (blood clots), Gastrostomy Status (pertaining to a tube placed into the stomach for the purpose of supplying food, fluids and medication), Cognitive Communication Deficit (difficulty communicating needs), Psychosis (severe mental disorder with loss of contact with reality), Generalized Anxiety, and Post Traumatic Seizures (a convulsive state following a head injury). Resident 9 had a family member who was his Responsible Party and acted in his behalf. Resident 9's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $ 0.57. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 9. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 9 and his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 9's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 9 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank document titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 9, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 9's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 9's wants and needs and improving the resident's quality of life. These violations, either separately or jointly had a direct or immediate relationship to Resident 9's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012408 |
B |
27-Jul-16 |
W2Y811 |
10439 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 10 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 10 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 10. As a result of these failures, Resident 10 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 10's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 10's clinical record titled, "Face Sheet" indicated Resident 10 was a 69 year old with diagnoses that included Convulsions (seizures), Paraplegia (inability to move the lower half of the body), End Stage Renal Disease (kidneys are damaged and cannot function properly), and Major Depressive Disorder (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period of time). Resident 10 was responsible for his own medical and financial affairs. Resident 10's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $98.78. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 10. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 10, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 10's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were and how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 10 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Review of bank document, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 10, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 10's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 10's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 10's health safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012409 |
B |
27-Jul-16 |
W2Y811 |
10281 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 11 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 11 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 11. As a result of these failures, Resident 11 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 11's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 11's clinical record titled, "Face Sheet" indicated Resident 11 was a 79 year old with diagnoses that included Chronic Pain due to Trauma (pain due to injury), and Essential Primary Hypertension( high blood pressure with no identifiable cause). Resident 11 was responsible for his own medical and financial affairs. Resident 11's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $88.00. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 11. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 11, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 11's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 11 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 11, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 11's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 11's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 11's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012410 |
B |
27-Jul-16 |
W2Y811 |
10351 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 12 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 12 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 12. As a result of these failures, Resident 12 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 12's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 12's clinical record titled, "Face Sheet" indicated Resident 12 was a 70 year old with diagnoses that included Hemiplegia (paralyzed on one side of the body), Type 2 Diabetes Mellitus (blood sugar disorder), and Psychosis (severe mental disorder resulting in loss of contact with reality). Resident 12 had a designated Responsible Party who acted on his behalf. Resident 12's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $1.78. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessment for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 12. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 12 and his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 12's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 12 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss...." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 12, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 12's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 12's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 12's health safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012412 |
B |
27-Jul-16 |
W2Y811 |
10358 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 13 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 13 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 13. As a result of these failures, Resident 13 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 13's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 13's clinical record titled, "Face Sheet" indicated Resident 13 was a 36 year old with diagnoses that included Quadriplegia (unable to move arms or legs), Convulsions (seizures), Head Injury, Anxiety, and Major Depressive Disorder (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period of time). Resident 13 was responsible for his own medical and financial affairs. Resident 13's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $5.36. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 13. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 13, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 13's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 13 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20, 000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 13, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 13's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 13's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 13's health, safety or security, and therefore constitute a Class "B" Citation. . |
| 040000061 |
Sunnyside Convalescent Hospital |
040012413 |
B |
27-Jul-16 |
W2Y811 |
10471 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 14 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 14 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 14. As a result of these failures, Resident 14 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 14's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 14's clinical record titled, "Face Sheet" indicated Resident 14 was a 90 year old with diagnoses that included Heart Disease, Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Anxiety, and Mental Disorders (a person's thoughts, emotions, or behavior are so abnormal as to cause suffering to himself, herself, or other people). Resident 14 had a friend who acted as the Responsible Party in her behalf. Resident 14's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $1,989.28. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 14. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 14 and her Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 14's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 14 or any of the 57 residents with in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 14, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 14's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 14's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 14's health, safety or security, and therefore constitute a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012414 |
B |
27-Jul-16 |
W2Y811 |
10533 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 15 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 15 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 15. As a result of these failures, Resident 15 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 15's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 15's clinical record titled, "Face Sheet" indicated Resident 15 was a 60 year old with diagnoses that included Heart Failure, Adult Failure to Thrive (weight loss and general decline), Cerebral Infarction (area of impaired circulation in the brain), Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), and Paranoid Schizophrenia (severe mental disorder that alters perception and thinking). Resident 15 had a designated Responsible Party who acted on his behalf. Resident 15's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $12.64. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 15. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 15 and his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 15's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 15 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 15, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 15's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 15's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 15's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012425 |
B |
27-Jul-16 |
W2Y811 |
10459 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 16 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 16 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 16. As a result of these failures, Resident 16 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 16's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 16's clinical record titled, "Face Sheet" indicated Resident 16 was a 70 year old with diagnoses that included Cellulitis (bacterial skin infection), Type 2 Diabetes Mellitus (high blood sugar, insulin resistance, and relative lack of insulin), Anxiety, and Depression. Resident 16 was responsible for management of her own affairs. On 5/18/16 at 9:50 a.m., during an interview, Resident 16 stated she never received a facility trust account statement indicating the balance in her account. Resident 16's facility generated "Trust Statement," dated 1/31/16, indicated a deficit balance of $-165.82. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated 1/1/15 through 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History," dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 16. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 16, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 16's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 16 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 16, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 16's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 16's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 16's, health, safety or security, and therefore constitutes a Class "B" Citation |
| 040000061 |
Sunnyside Convalescent Hospital |
040012426 |
B |
27-Jul-16 |
W2Y811 |
10394 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 18 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 18 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 18. As a result of these failures, Resident 18 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 18's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 18's clinical record titled, "Face Sheet" indicated Resident 18 was 51 years old with diagnoses that included Diabetes Mellitus (blood sugar disorder), Acquired Absence of Limb, Major Depressive Disorder (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period of time), and Severe Sepsis (life threatening bacterial infection). Resident 18 was responsible for management of his own affairs. Resident 18's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $0.00. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MD (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 18. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 18, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 18's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 18 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1," dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 18, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 18's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 18's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 18's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012427 |
B |
27-Jul-16 |
W2Y811 |
10527 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 ? Safeguards for Patients? Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients? monies and valuables entrusted to the licensee?s care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient?s behalf. (A) Records of patients? monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance?.At no time may the balance in a patient?s drawing account be less than zero. (5) ?Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients? funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 19 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident?s consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 19 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 19. As a result of these failures, Resident 19 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 19?s consent to benefit the O/AD when it should have been used to meet the resident?s personal wants and needs and improve the resident?s quality of life. Review of Resident 19?s clinical record titled, ?Face Sheet? indicated Resident 19 was a 46 year old with diagnoses that included Intracerebral Hemorrhage (bleeding into the brain), Head Injury, Bipolar Disorder (severe high and low moods and changes in sleep, energy, thinking, and behavior), Gastrostomy tube status (pertaining to a tube placed into the stomach for the purpose of supplying food and medication), Restlessness and Agitation (never at rest; perpetually agitated or in motion). Resident 19 had a friend that acted as the Responsible Party in his behalf. Resident 19?s facility generated ?Trust Statement,? dated 1/31/16, indicated a closing balance of $7.00. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, ??Your combined statement from the bank?? dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, ?Trust-Transaction History? dated 1/1/15 through 12/30/15, indicated a total of 57 residents? monies were in the trust account, including Resident 19. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 19 and his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 19?s trust account generated by the facility had not represented the real balance on the account. The O/AD stated, ?I give them statements with what money should be in the account, not what is really in the account?? The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, ?All I know is that I owe all the suppliers money.? The O/AD was unable to provide itemized receipts for Resident 19 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD?s business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits? indicated a transfer of $20,000 was made to account **** (O/AD?s business account) dated 6/24/15. Bank document ?Resident Trust Account 1,? dated 8/1/15 to 8/30/15 indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, ?What Are My Rights and Protections in a Nursing Home? indicated ??The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can?t combine your funds with the nursing home?s funds. The nursing home must protect your funds from any loss?? Review of an undated letter addressed to ?Nursing Home Administrator Program,? date stamped received 5/25/16, and signed by the O/AD indicated, ?We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account?I knew that this was wrong but I made the decision.? Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 19, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 19?s personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 19?s wants and needs and improving the resident?s quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 19?s, health, safety or security, and therefore constitutes a Class ?B? Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012430 |
B |
27-Jul-16 |
W2Y811 |
10841 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 21 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 21 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 21. As a result of these failures, Resident 21 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 21's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 21's clinical record titled, "Face Sheet" indicated Resident 21 was 72 years old with diagnoses which included Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Diabetes Mellitus, and Convulsions (Seizures). Resident 21 was not able to manage his own affairs and had a Responsible Party. Resident 21's facility generated "Trust Statement" dated 12/31/15, indicated a closing deficit balance of $-20.00. Resident 21's facility generated "Trust Statement" dated 1/31/16, indicated a closing deficit balance of $-20.00. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 21. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 21 and his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 21's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 21 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. California Audits and Investigations Financial Audits Branch document titled, "Summary of Findings" (a report summary of the facility trust account audit, period of review 1/1/15 to 2/29/16) indicated under Finding 4 Recommendations: "The provider should have appropriate controls in place to ensure that the patient's trust account never falls below zero." Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 21, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 21's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 21's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 21's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012431 |
B |
27-Jul-16 |
W2Y811 |
10339 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 ? Safeguards for Patients? Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients? monies and valuables entrusted to the licensee?s care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient?s behalf. (A) Records of patients? monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance?.At no time may the balance in a patient?s drawing account be less than zero. (5) ?Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients? funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 22 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident?s consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 22 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 22. As a result of these failures, Resident 22 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 22?s consent to benefit the O/AD when it should have been used to meet the resident?s personal wants and needs and improve the resident?s quality of life. Resident 22?s clinical record titled, ?Face Sheet? indicated Resident 22 was 72 years old with diagnoses which included Parkinson?s Disease (a degenerative disorder of the central nervous system), Major Depressive Disorder(severe sadness, and feelings of worthlessness and hopelessness), and Severe Sepsis (life threatening bacterial infection). Resident 22 was not able to manage her own affairs and had a Responsible Party who acted on her behalf. Resident 22?s facility generated ?Trust Statement? dated 1/31/16 indicated a closing balance of $4.00. On 3/9/ 16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, ??Your combined statement from the bank?? dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled ?Trust-Transaction History? dated 1/1/15 through 12/30/15, indicated a total of 57 residents? monies were in the trust account, including Resident 22. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 22 and her Responsible Party were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 22?s trust account generated by the facility had not represented the real balance on the account. The O/AD stated, ?I give them statements with what money should be in the account, not what is really in the account?? The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, ?All I know is that I owe all the suppliers money.? The O/AD was unable to provide itemized receipts for Resident 22 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD?s business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits? indicated a transfer of $20,000 was made to account **** (O/AD?s business account) dated 6/24/15. Bank document titled, ?Resident Trust Account 1,? dated, 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, ?What Are My Rights and Protections in a Nursing Home? indicated ??The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can?t combine your funds with the nursing home?s funds. The nursing home must protect your funds from any loss?? Review of an undated letter addressed to ?Nursing Home Administrator Program,? date stamped received 5/25/16, and signed by the O/AD indicated, ?We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account?I knew that this was wrong but I made the decision.? Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 22, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 22?s personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 22?s wants and needs and improving the resident?s quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 22?s health, safety or security, and therefore constitutes a Class ?B? Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012433 |
B |
27-Jul-16 |
W2Y811 |
10226 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 23 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 23 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 23. As a result of these failures, Resident 23 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 23's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 23's clinical record titled, "Face Sheet" indicated Resident 23 was 68 years old with diagnoses that included Altered Mental Status (disruption in how the brain works that causes a change in behavior), and Diabetes Mellitus. Resident 23 managed her own affairs. Resident 23's facility generated "Trust Statement" dated 1/31/16, indicated a closing balance of $252.13. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 23. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 23, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 23's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 23 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 23, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 23's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 23's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 23's health, safety or security, and therefore constitute a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012434 |
B |
27-Jul-16 |
W2Y811 |
10324 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 24 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 24 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 24. As a result of these failures, Resident 24 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 24's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 24's clinical record titled, "Face Sheet" indicated Resident 24 was a 70 year old with diagnoses that included Non-Traumatic Subdural Hemorrhage (rupture of brain vessels not caused by trauma injuries), Unspecified Atrial Fibrillation (an irregular and often very fast heart rate), and Dysphagia (difficulty swallowing) Resident 24 managed his own affairs. Resident 24's facility generated "Trust Statement" dated 1/31/16, indicated a closing balance of $1,462.94. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 24. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 24, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 24's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 24 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 24, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 24's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 24's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 24's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012436 |
B |
27-Jul-16 |
W2Y811 |
10331 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 26 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 26 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 26. As a result of these failures, Resident 26 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 26's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 26's clinical record titled, "Face Sheet" indicated Resident 26 was a 49 year old with diagnoses that included Altered Mental Status (disruption in how the brain works), and Chronic Kidney Disease (kidneys not working properly). Resident 26 was not able to manage her own affairs and had had a Responsible Party who acted on her behalf. Resident 26's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $852.19. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 26. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 26 and her Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 26's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 26 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated, 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 26, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 26's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 26's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 26's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012437 |
B |
27-Jul-16 |
W2Y811 |
9574 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 27 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 27 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 27. As a result of these failures, Resident 27 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 27's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 27's clinical record titled, "Face Sheet" indicated Resident 27 was a 59 year old with diagnoses that included Vascular Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), and Hemiplegia (paralyzed one side of the body). Resident 27 was not able to manage her own affairs and had a Responsible Party (RP) who acted on her behalf. Resident 27's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $1,992.92. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 27. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 27 and her Responsible Party (RP), were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 27's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 27 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 27, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 27's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 27's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 27's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012438 |
B |
27-Jul-16 |
W2Y811 |
10341 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 29 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 29 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 29. As a result of these failures, Resident 29 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 29's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 29's clinical record titled, "Face Sheet" indicated Resident 29 was a 40 year old with diagnoses that included Quadriplegia (paralysis of both arms and both legs), and Gastrointestinal Hemorrhage (bleeding in the stomach, intestines, bleeding from the mouth to the rectum). Resident 29 was not able to manage his own affairs and had a Responsible Party who acted on his behalf. Resident 29's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $2.79. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 29. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 29 and his Responsible Party (RP), were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 29's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 29 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process on how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 29, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 29's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 29's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 29's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012439 |
B |
27-Jul-16 |
W2Y811 |
10966 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 25 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 25 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 25. As a result of these failures, Resident 25 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 25's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 25's clinical record titled, "Face Sheet" indicated Resident 25 was 80 years old with diagnoses that included Acute Kidney Failure (kidneys not functioning properly), Psychosis (severe mental disorder with impaired thought and emotions), and Acute and Chronic Respiratory Disease. Resident 25 was not able to manage her own affairs and had a Responsible Party who acted on her behalf. Resident 25's facility generated "Trust Statement" dated 1/31/16, indicated a deficit balance of -$1.85. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 25. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 25 and her Responsible, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 25's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 25 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. On 5/18/16 at 2 p.m., during an attempted interview, Resident 25 was non-interview able. On 5/18/16 at 3:15 p.m., during an interview, Resident 25's Responsible Party (RP) stated the facility never provided trust account statements to her. California Audits and Investigations Financial Audits Branch document titled, "Summary of Findings" (a report summary of the facility trust account audit, period of review 1/1/15 to 2/29/16) indicated under Finding 4 Recommendations: "The provider should have appropriate controls in place to ensure that the patient's trust account never falls below zero." Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 25, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 25's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 25's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 25's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012440 |
B |
27-Jul-16 |
W2Y811 |
10295 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 30 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 30 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 30. As a result of these failures, Resident 30 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 30's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 30's clinical record titled, "Face Sheet" indicated Resident 30 was a 58 year old with diagnoses that included Heart Failure (heart has lost the ability to pump enough blood to the body's tissues), and Type 2 Diabetes Mellitus (high blood sugar, insulin resistance, and relative lack of insulin). Resident 30 was able to manage his own affairs. Resident 30's facility generated "Trust Statement," dated 11/30/15, indicated a closing balance of $0.00. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 30. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 30, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 30's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 30 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1" dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 30, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 30's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 30's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 30's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012441 |
B |
27-Jul-16 |
W2Y811 |
10372 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 31 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks or outings) from unauthorized or wrongful use. 3. Protect Resident 31 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 31. As a result of these failures, Resident 31 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 31's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Review of Resident 31's clinical record titled, "Face Sheet" indicated Resident 31 was a 64 year old with diagnoses that included Heart Failure (heart has lost the ability to pump enough blood to the body's tissue), and Type 2 Diabetes Mellitus (high blood sugar, insulin resistance, and relative lack of insulin). Resident 31 was not able to manage her own affairs and had an appointed guardian. Resident 31's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $544.94. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 31. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 31 and her Guardian, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 31's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 31 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of residents trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1" dated, 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 31, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 31's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 31's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 31's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012442 |
B |
27-Jul-16 |
W2Y811 |
10280 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 33 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 33 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 33. As a result of these failures, Resident 33 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 33's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the Resident 33's clinical record titled, "Face Sheet" indicated Resident 33 was a 78 year old with diagnoses that included Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities),and Peripheral Vascular Disease (inadequate blood flow to the legs). Resident 33 was able to manage his own affairs. Resident 33's "Trust Statement," dated 1/31/16, indicated a closing balance of $1,922.12. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 33. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 33, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 33's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 33 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 33, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 33's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 33's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 33's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012443 |
B |
27-Jul-16 |
W2Y811 |
10422 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 34 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 34 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 34. As a result of these failures, Resident 34 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 34's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 34's clinical record titled, "Face Sheet" indicated Resident 34 was a 70 year old with diagnoses that included Chronic Kidney Disease (kidneys not functioning properly), Malignant Neoplasm of the Esophagus (cancer of the throat), Pyothorax (pus in the chest cavity), Anxiety, and Major Depressive Disorder (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period of time). Resident 34 was able to manage his own affairs. Resident 34's facility generated "Trust Statement," dated 1/31/16 indicated a closing balance of $18.50. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 34. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 34, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 34's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 34 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 34, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 34's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 34's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 34's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012444 |
B |
27-Jul-16 |
W2Y811 |
10394 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 35 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 35 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 35. As a result of these failures, Resident 35 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 35's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Review of Resident 35's clinical record titled "Face Sheet" indicated Resident 35 was a 62 year old with diagnoses that included Cerebrovascular Disease (disease of the blood vessels of the brain), Psychosis (severe mental disorder), and Multiple Sclerosis (disease of the brain and spinal cord). Resident 35 was not able to manage her own affairs and had a Responsible Party who acted on her behalf. Review of Resident 35's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $918.15. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 35. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 35 and her Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 35's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 35 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 35, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 35's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 35's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 35's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012445 |
B |
27-Jul-16 |
W2Y811 |
10357 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 36 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 36 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 36. As a result of these failures, Resident 36 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 36's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 36's clinical record titled, "Face Sheet" indicated Resident 36 was a 58 year old with diagnoses that included Liver Disease (condition that stops the liver from working or prevents it from functioning well), Type 2 Diabetes Mellitus (blood sugar disorder), and Major Depressive Disorder (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period of time). Resident 36's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $0.57. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 36. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 36, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 36's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 36 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 36, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 36's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 36's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 36's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012449 |
B |
27-Jul-16 |
W2Y811 |
10439 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 37 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 37 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 37. As a result of these failures, Resident 37 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 37's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 37's clinical record titled, "Face Sheet" indicated Resident 37 was a 78 year old with diagnoses that included Hepatic Failure (liver not functioning properly), Type 2 Diabetes Mellitus (blood sugar disorder), Heart Failure (the heart is unable to pump blood adequately to meet the needs of the body), and Major Depressive Disorder (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period of time). Resident 37 was able to manage his own affairs. Resident 37's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $157.72. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 37. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 37, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 37's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 37 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 37, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 37's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 37's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 37's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012450 |
B |
27-Jul-16 |
W2Y811 |
10370 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 38 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 38 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 38. As a result of these failures, Resident 38 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 38's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 38's clinical record titled, "Face Sheet" indicated Resident 38 was a 60 year old with diagnoses that included Hepatic Failure (liver not functioning properly), Infection of the Vertebrae (bones that surround the spinal cord), and Depression (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period of time). Resident 38 was able to manage his own affairs. Review of Resident 38's facility generated "Trust Statement," dated 12/31/15, indicated a closing balance of $0.00. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 38. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 38, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 38's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 38 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 38, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 38's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 38's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 38's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012451 |
B |
27-Jul-16 |
W2Y811 |
10557 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 40 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 40 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 40. As a result of these failures, Resident 40 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 40's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 40's clinical record titled, "Face Sheet" indicated Resident 40 was a 62 year old with diagnoses that included Acute Kidney Failure (kidneys not functioning properly), Heart Failure (heart is unable to pump blood adequately to meet the needs of the body), Cerebrovascular Disease (disease of the blood vessels of the brain), and Major Depressive Disorder (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period of time). Resident 40 was not able to manage his own affairs and had a Responsible Party who acted on his behalf. Resident 40's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $277.95. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 40. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 40 and his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 40's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 40 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled. "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 40, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 40's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 40's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 40's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012452 |
B |
27-Jul-16 |
W2Y811 |
10471 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 41 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 41 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 41. As a result of these failures, Resident 41 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 41's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 41's clinical record titled, "Face Sheet" indicated Resident 41 was a 61 year old with diagnoses that included Malignant Neoplasm (cancer), Psychosis (severe mental disorder with loss of contact with reality), Heart Failure (inability of the heart to pump adequately to meet the needs of the body), and Chronic Obstructive Pulmonary Disorder (lung disorder causing difficulty in breathing). Resident 41 was not able to manage his own affairs and had an appointed Public Guardian. Resident 41's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $349.75. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 41. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 41 and his Public Guardian, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 41's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 41 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled "Deposits and other Credits" indicated a transfer of $20, 000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 41, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 41's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 41's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 41's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012453 |
B |
27-Jul-16 |
W2Y811 |
10506 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 43 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 43 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 43. As a result of these failures, Resident 43 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 43's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 43's clinical record titled, "Face Sheet" indicated Resident 43 was a 72 year old with diagnoses that included Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Hepatic Failure (liver failure), and Major Depressive Disorder (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period of time). Resident 43 was not able to manage his own affairs and had a Responsible Party who acted on his behalf. Resident 43's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $50.00. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 43. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 43 and his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 43's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 43 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 43, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 43's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 43's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 43's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012454 |
B |
27-Jul-16 |
W2Y811 |
10415 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 44 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks or outings) from unauthorized or wrongful use. 3. Protect Resident 44 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 44. As a result of these failures, Resident 44 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 44's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 44's clinical record titled, "Face Sheet" indicated Resident 44 was a 54 year old with diagnoses that included Schizophrenia (major mental disorder causing delusions and impaired contact with reality), Head Injury, and Major Depressive Disorder (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period of time). Resident 44 was not able to manage her own affairs and had an appointed Public Guardian. Resident 44's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $ 404.48. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 44. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 44 and her Public Guardian, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 44's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 44 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 44, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 44's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 44's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 44's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012455 |
B |
27-Jul-16 |
W2Y811 |
10452 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 45 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 45 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 45. As a result of these failures, Resident 45 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 45's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 45's clinical record titled, "Face Sheet" indicated Resident 45 was a 46 year old with diagnoses that included Schizophrenia (major mental disorder causing delusions and impaired contact with reality), Heart Disease, Hypertension (high blood pressure), and Major Depressive Disorder (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period of time). Resident 45 was not able to manage her own affairs and had an appointed Guardian. Resident 45's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $10.17. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 45. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 45 and her Guardian, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 45's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 45 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 45, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 45's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 45's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 45's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012456 |
B |
27-Jul-16 |
W2Y811 |
10430 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 46 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 46 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 46. As a result of these failures, Resident 46 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 46's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 46's clinical record titled, "Face Sheet" indicated Resident 46 was a 65 year old with diagnoses that included Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Convulsions (seizures), Profound Intellectual Disability, and Adult Failure to Thrive (weight loss and general decline). Resident 46 was not able to manage her own affairs and had an appointed Guardian. Resident 46's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $1,221.96. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 46. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 46 and her Guardian, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 46's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 46 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1" dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 46, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 46's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 46's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 46's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012457 |
B |
27-Jul-16 |
W2Y811 |
10358 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 47 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 47 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 47. As a result of these failures, Resident 47 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 47's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 47's clinical record titled, "Face Sheet" indicated Resident 47 was a 39 year old with diagnoses that included Schizophrenia (major mental disorder causing delusions and impaired contact with reality), Heart Disease, and End Stage Renal Disease (kidney failure). Resident 47 was not able to manage his own affairs and had a Responsible Party who acted on his behalf. Resident 47's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $0.77. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 47. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 47 and his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 47's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 47 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 47, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 47's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 47's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 47's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012458 |
B |
27-Jul-16 |
W2Y811 |
10571 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 48 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 48 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 48. As a result of these failures, Resident 48 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 48's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the quality of life. Resident 48's clinical record titled, "Face Sheet" indicated Resident 48 was a 68 year old with diagnoses that included Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Hemiplegia (paralysis of one side of the body), Diabetes Mellitus (disorder of insulin production affecting blood sugar levels), and Major Depressive Disorder (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period of time). Resident 48 was not able to manage her own affairs and had a Responsible Party who acted on her behalf. Resident 48's "Trust Statement," dated 1/31/16, indicated a closing balance of $20.66. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 48. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 48 and her Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 48's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 48 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 48, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 48's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 48's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 48's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012459 |
B |
27-Jul-16 |
W2Y811 |
10347 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 49 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 49 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 49. As a result of these failures, Resident 49 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 49's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the quality of life. Resident 49's clinical record titled, "Face Sheet" indicated Resident 49 was an 84 year old with diagnoses that included unspecified Hemiplegia (paralysis on one side of the body) and Major Depressive Disorder (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period of time). Resident 49 was able to manage his own affairs and had no appointed guardian. Resident 49's "Trust Statement," dated 1/31/16, indicated a closing balance of $2,299.97. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 49. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 49 or his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 49's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 49 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 49, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 49's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 49's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 49's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012460 |
B |
27-Jul-16 |
W2Y811 |
10463 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 50 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 50 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 50. As a result of these failures, Resident 50 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 50's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 50's clinical record titled, "Face Sheet" indicated Resident 50 was a 69 year old with diagnoses that included Hemiplegia (paralysis on one side of the body), Convulsions (seizures), Schizophrenia (severe mental disorder causing delusions and loss of contact with reality), and Major Depressive Disorder (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period of time). Resident 50 was responsible to manage his own affairs and had no appointed guardian. Resident 50's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $2,014.80. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 50. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 50, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 50's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 50 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20, 000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1" dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 50, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 50's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 50's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 50's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012462 |
B |
27-Jul-16 |
W2Y811 |
10473 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 51 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 51 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 51. As a result of these failures, Resident 51 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 51's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 51's clinical record titled, "Face Sheet" indicated Resident 51 was a 59 year old with diagnoses that included Malignant Neoplasm of the Colon (colon cancer), Type 2 Diabetes Mellitus (disorder affecting blood sugar level), Schizophrenia (severe mental disorder causing delusions and impaired contact with reality), and Essential Primary Hypertension ( high blood pressure). Resident 51 was not able to manage her own affairs and had a Responsible Party who acted on her behalf. Resident 51's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $137.72. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 51. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 51 and her Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 51's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 51 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 51, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 51's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 51's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 51's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012464 |
B |
27-Jul-16 |
W2Y811 |
10516 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 52 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 52 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 52. As a result of these failures, Resident 52 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 52's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 52's clinical record titled, "Face Sheet" indicated Resident 52 was a 70 year old with diagnoses that included Type 2 Diabetes Mellitus (disorder that affects blood sugar level), Heart Failure (inability of the heart to pump blood adequately to meet the needs of the body), Convulsions (seizures), Psychosis (severe mental disorder with loss of contact with reality), and Hypertension (high blood pressure). Resident 52 was not able to manage her own affairs and had a Responsible Party who acted on her behalf. Review of Resident 52's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $956.80. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 52. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 52 and her Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 52's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 52 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1" dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 52, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 52's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 52's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 52's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012466 |
B |
27-Jul-16 |
W2Y811 |
10328 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 54 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 54 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 54. As a result of these failures, Resident 54 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 54's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 54's clinical record titled, "Face Sheet" indicated Resident 54 was a 54 year old with diagnoses that included Schizophrenia (severe mental disorder with delusions and impaired contact with reality), Burns, and Anxiety Disorder. Resident 54 was not able to manage his own affairs, and had a Responsible Party who acted on his behalf. Resident 54's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $20.52. n 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 54. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 54 and his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 54's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 54 or any of the 57 residents who had money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank document titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 54, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 54's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 54's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 54's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012468 |
B |
27-Jul-16 |
W2Y811 |
10742 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 55 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 55 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 55. As a result of these failures, Resident 55 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 55's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 55's clinical record titled, "Face Sheet" indicated Resident 55 was a 58 year old with diagnoses that included Major Depressive Disorder (mental illness characterized by a profound and persistent feeling of sadness), and Heart Failure (inability of the heart to pump blood adequately to meet the needs of the body). Resident 55 was not able to manage his own affairs and had a Responsible Party who acted on his behalf. Review of Resident 55's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $11.35. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 55. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 55 and his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 55's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 55 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. On 5/18/16 at 1:45 p.m., during an interview, Resident 55 stated he never received monthly bank statements. Resident 55 stated he liked to buy "munchies" but did not receive money when he asked. On 5/18/16 at 2:30 p.m. during an interview, the Business Office Clerk stated Resident 55 did not have money in his account. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1" dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 55, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 55's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 55's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 55's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012471 |
B |
27-Jul-16 |
W2Y811 |
10484 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 ? Safeguards for Patients? Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients? monies and valuables entrusted to the licensee?s care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient?s behalf. (A) Records of patients? monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance?.At no time may the balance in a patient?s drawing account be less than zero. (5) ?Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients? funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 56 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident?s consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks or outings) from unauthorized or wrongful use. 3. Protect Resident 56 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 56. As a result of these failures, Resident 56 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 56?s consent to benefit the O/AD when it should have been used to meet the resident?s personal wants and needs and improve the resident?s quality of life. Resident 56?s clinical record titled. ?Face Sheet? indicated Resident 56 was a 49 year old with diagnoses that included Major Depressive Disorder (severe sadness, along with feeling worthless, hopeless, and helpless over a prolonged period of time), Hemiplegia (paralysis on one side of the body), Convulsions (seizures), and Cerebrovascular Disease (conditions that affect the circulation of blood to the brain). Resident 56 was not able to manage his own affairs and had a Responsible Party who acted on his behalf. Resident 56?s facility generated ?Trust Statement,? dated 1/31/16, indicated a closing balance of $780.76. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, ??Your combined statement from the bank?? dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, ?Trust-Transaction History? dated 1/1/15 through 12/30/15, indicated a total of 57 residents? monies were in the trust account, including Resident 56. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 56 and his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 56?s trust account generated by the facility had not represented the real balance on the account. The O/AD stated, ?I give them statements with what money should be in the account, not what is really in the account?? The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, ?All I know is that I owe all the suppliers money.? The O/AD was unable to provide itemized receipts for Resident 56 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD?s business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits? indicated a transfer of $20,000 was made to account **** (O/AD?s business account) dated 6/24/15. Bank document titled, ?Resident Trust Account 1? dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, ?What Are My Rights and Protections in a Nursing Home? indicated ??The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can?t combine your funds with the nursing home?s funds. The nursing home must protect your funds from any loss?? Review of an undated letter addressed to ?Nursing Home Administrator Program,? date stamped received 5/25/16, and signed by the O/AD indicated, ?We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account?I knew that this was wrong but I made the decision.? Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 56, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 56?s personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 56?s wants and needs and improving the resident?s quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 56?s, health, safety or security, and therefore constitutes a Class ?B? Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012473 |
B |
27-Jul-16 |
W2Y811 |
10367 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 57 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 57 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 57. As a result of these failures, Resident 57 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 57's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 57's clinical record titled, "Face Sheet" indicated Resident 57 was a 70 year old with diagnoses that included Chronic Kidney Disease (kidneys not functioning properly), Hemiplegia (paralysis on one side of the body), Anxiety, and Severe Sepsis (infection in the blood). Resident 57 was not able to manage his own affairs and had a Responsible Party who acted on his behalf. Resident 57's facility generated "Trust Statement," dated 1/31/16, indicated a closing balance of $553.16. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 57. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 57 and his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 57's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 57 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1" dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss..." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 57, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 57's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 57's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 57's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012475 |
B |
27-Jul-16 |
W2Y811 |
11246 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 20 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 20 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 20. As a result of these failures, Resident 20 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 20's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 20's clinical record titled, "Face Sheet" indicated Resident 20 was 78 years old with diagnoses that included Schizophrenia (severe mental disorder causing delusions and impaired perception of reality), Malignant Neoplasm of Pancreas (cancer of the pancreas) and Hip Fracture. Resident 20 expired 12/21/15. He was not able to manage his own affairs and had an appointed Public Guardian. Resident 20's facility generated "Trust Statement" dated 1/31/16, indicated a closing balance of $1,012.41. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 20. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 20 and his Public Guardian, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 20's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 20 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1" dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. On 5/17/16 at 10:35 a.m., during an interview, Resident 20's Public Guardian stated Resident 20 expired 12/21/15, and the trust funds were returned to the Public Guardian's office on 3/16/16, more than 30 days after the resident expired. California Audits and Investigations Financial Audits Branch document titled, "Summary of Findings" (a summary report of the facility trust account audit, period of review 1/1/15 to 2/29/16), conducted in March 2016, indicated under Recommendations, "The provider should have appropriate controls in place to ensure that the clients' trust fund is being handled properly. The trust fund monies should be made available...within 30 days of the date of death." Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss...If a resident with a fund passes away, the nursing home must return the funds with a final accounting to the person or court handling the resident's estate within 30 days." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 20, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 20's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 20's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 20's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012476 |
B |
27-Jul-16 |
W2Y811 |
12108 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 28 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 28 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 28. As a result of these failures, Resident 28 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 28's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 28's clinical record titled, "Face Sheet" indicated Resident 28 was 82 years old with diagnoses of Renal Failure (loss of kidney function), Senile Dementia (loss of thinking skills and memory severe enough to reduce the ability to perform everyday activities), Alzheimer's Disease (progressive mental deterioration due to generalized degeneration of the brain), and Schizophrenia (a mental disorder with breakdown between thought, emotion, and behavior). Resident 28 was not able to manage his own affairs and had a Responsible Party (RP) who acted on his behalf. Resident 28 expired 8/3/15. Resident 28's facility generated "Trust Statement" dated 1/31/16, indicated a closing balance of $664.71. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 28. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 28 and his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 28's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 28 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1," dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 has been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. On 5/17/16 at 11 a.m., during a telephone interview, Resident 28's RP stated he was traveling and unable to speak on the phone. The RP stated Family Member (FM) 1 was knowledgeable regarding Resident 28's trust fund account and was able to provide information regarding the trust fund. On 5/17/16 at 11:30 a.m., during a telephone interview, FM 1 stated Resident 28 expired on 8/3/15. FM 1 stated facility trust account statements were not provided to her or to Resident 28's RP, and no funds were returned to the family or the RP after the resident's death. FM 1 further stated she and the RP were told the facility used the funds for Resident 28's burial expenses. California Audits and Investigations Financial Audits Branch document titled, "Summary of Findings" (a report summary of the facility trust account audit, period of review 1/1/15 to 2/29/16), conducted in March 2016, indicated under Finding 7, "[Resident 28] expired on 8/3/15 with a trust fund balance of $664.71. The trust funds have not been returned to the patient's representative." It further stated under Recommendations, "The provider should have appropriate controls in place to ensure that the clients' trust fund is being handled properly. The trust fund monies should be made available...within 30 days of the date of death. The patient/representative should be refunded..." Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss...If a resident with a fund passes away, the nursing home must return the funds with a final accounting to the person or court handling the resident's estate within 30 days." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 28, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 28's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 28's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 28's health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012477 |
B |
27-Jul-16 |
W2Y811 |
11617 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 42 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snacks, or outings) from unauthorized or wrongful use. 3. Protect Resident 42 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 42. As a result of these failures, Resident 42 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 42's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 42's clinical record titled, "Face Sheet" indicated Resident 42 was 51 years old with diagnoses that included Type 2 Diabetes (high blood sugar, insulin resistance, and relative lack of insulin), Paraplegia (paralysis in lower part of body including legs), and Depression. Resident 42 was not able to manage his own affairs and had a Responsible Party (RP) who acted on his behalf. Resident 42 expired 12/15/15. Resident 42's facility generated "Trust Statement" dated 1/31/16, indicated a closing balance of $1645.59. On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 42. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 42 and his Responsible Party, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 42's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 42 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of resident trust accounts. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1" dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. On 5/17/16 at 10:45 a.m., during an interview, Resident 42's Responsible Party stated Resident 42 expired on 12/15/15, and the facility told him the remainder of Resident 42's money had to be returned to the Social Security Administration Office. He further stated he knew there was approximately $1200 in Resident 42's account. The RP stated no funds were returned to him. California Audits and Investigations Financial Audits Branch document titled, "Summary of Findings" (a summary report of the facility trust account audit, period of review 1/1/15 to 2/29/16), conducted in March 2016, indicated under Finding 7, that Resident 42 expired in December 2015 with a trust fund balance of $1645.59. His balance was not returned to Resident 42's Responsible Party. It further stated, "The provider should have appropriate controls in place to ensure that the clients' trust fund is being handled properly. The trust fund monies should be made available...within 30 days of the date of death. The patient/representative should be refunded..." Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss...If a resident with a fund passes away, the nursing home must return the funds with a final accounting to the person or court handling the resident's estate within 30 days." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 42, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 42's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 42's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 42's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 040000061 |
Sunnyside Convalescent Hospital |
040012478 |
B |
27-Jul-16 |
W2Y811 |
11794 |
F224 483.13(c) Staff treatment of Residents. The facility must develop and implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. California Code of Regulations, Title 22, Section 72527 - Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To manage personal financial affairs, or to be given at least a quarterly accounting of financial transactions made on the patient's behalf should the facility accept written delegation of this responsibility subject to the provisions of Section 72529. California Code of Regulations, Title 22, and Section 72529 - Safeguards for Patients' Monies and Valuables. (a) Each facility to whom a patient's money or valuables have been entrusted shall comply with the following: (1) No licensee shall mingle patients' monies or valuables with that of the licensee or the facility. Patients' monies and valuables shall be maintained separate, intact and free from any liability that the licensee incurs in the use of the licensee's or the facility's funds. The provisions of this section shall not be interpreted to preclude prosecution for the fraudulent appropriation of patients' monies or valuables as theft, as defined by Section 484 of the Penal Code. (2) Each licensee shall maintain safeguards and accurate records of patients' monies and valuables entrusted to the licensee's care including the maintenance of a detailed inventory and at least a quarterly accounting of financial transactions made on the patient's behalf. (A) Records of patients' monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each patient and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance....At no time may the balance in a patient's drawing account be less than zero. (5) ...Expenditures from the patient fund account shall only be for the immediate benefit of that particular patient. (e) For purposes of this section, patients' funds maintained in a financial institution shall be deemed to be entrusted to a facility if the licensee, or any agent or employee thereof, is an authorized signatory to said account. On 12/30/15 the California Department of Public Health Licensing and Certification Program made an unannounced visit to investigate anonymous complaint CA00468935 regarding alleged Fiduciary Abuse by the Owner/Administrator (O/AD) of the facility. The facility failed to: 1. Ensure Resident 53 was afforded the right to be protected from misappropriation (deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident belongings or money without resident's consent) of property. 2. Ensure policies and procedures were in place to protect resident trust accounts (monies deposited by residents into an account maintained by the facility and used to pay their personal expenses such as haircuts, snack, or outings) from unauthorized or wrongful use. 3. Protect Resident 53 from wrongful use of funds in a resident trust account when the O/AD withdrew monies from the resident trust account for the purpose of meeting financial obligations of the O/AD without the knowledge or consent of Resident 53. As a result of these failures, Resident 53 received an inaccurate monthly trust account statement generated by the facility and money from the trust account was wrongfully used without Resident 53's consent to benefit the O/AD when it should have been used to meet the resident's personal wants and needs and improve the resident's quality of life. Resident 53's clinical record titled, "Face Sheet" indicated Resident 53 was 80 years old with diagnoses of Psychosis (mental disorder with impairment of thought, emotion, and contact with reality), Ulcerative Colitis (inflammatory bowel disease that causes ulcers in the colon), Gastrointestinal Hemorrhage (bleeding in the stomach and intestines), and Hand Contracture (fibrosis of connective tissue causing limited mobility). Resident 53 was not able to manage his own affairs and had an appointed Public Guardian. Resident 53 expired 6/25/15. Resident 53's facility generated "Trust Statement" dated 1/31/16, indicated a closing balance of $1,195.35 On 3/9/16 at 10:25 a.m., during a telephone interview, Licensed Vocational Nurse (LVN) 1/MDS (Minimum Data Set) assessment Coordinator (responsible for coordination of resident assessments for physical and cognitive abilities) stated she voluntarily left her position at the facility in December 2015. LVN 1 stated while she was employed at the facility residents had complained they could not get information on their trust accounts. LVN 1 stated the business office was always closed. Bank documents for the facility titled, "...Your combined statement from the bank..." dated from 1/1/15 to 12/30/15, indicated the facility had two accounts for resident trust accounts. Trust Account 1 was a checking account and Trust Account 2 was a savings account. Facility documents titled, "Trust-Transaction History" dated 1/1/15 through 12/30/15, indicated a total of 57 residents' monies were in the trust account, including Resident 53. On 3/9/16 at 1:15 p.m., during an interview, the O/AD stated he was responsible for the resident trust accounts. The O/AD stated there was no facility process or policy or procedure to direct how money was withdrawn or deposited in the accounts or how to safeguard the trust accounts. The O/AD stated when checks came in he would deposit the checks in the resident trust account at the bank and provide each resident with a monthly statement of the account. When questioned regarding discrepancies between the resident trust account documents generated by the facility and the bank documents dated from 1/1/15 to 12/30/15, the O/AD stated he "borrowed" $20,000.00 on 6/24/15 from Trust Account 1 and transferred the money to his own business account to meet payroll and pay facility bills. On 3/9/16 at 1:25 p.m., during an interview, the O/AD also stated residents of the facility, including Resident 53 and his Guardian, were not aware he had removed money from the account. The O/AD stated the monthly statement for Resident 53's trust account generated by the facility had not represented the real balance on the account. The O/AD stated, "I give them statements with what money should be in the account, not what is really in the account..." The O/AD stated he had not returned the $20,000 to resident Trust Account 1 and did not know when or how he would return the money owed to the resident trust account. The O/AD stated he did not have the money to repay the trust account. The O/AD stated he owed money to the companies that provided supplies to the facility. The O/AD stated he did not have a list of the suppliers and did not keep records (ledger) of who they were or how much money was owed to them. The O/AD stated, "All I know is that I owe all the suppliers money." The O/AD was unable to provide itemized receipts for Resident 53 or any of the 57 residents with money in Trust Account 1 and Trust Account 2. On 3/9/16 at 1:35 p.m., during an interview, the O/AD stated he did not have a process for handling the resident trust accounts. When asked, the O/AD was unable to provide a policy and procedure for the handling of residents trust account. The O/AD stated when resident checks arrived he made a deposit in the residents combined trust accounts. The O/AD stated he did not have a process for how to deposit and withdraw funds from the bank accounts. The O/AD stated when he needed money he made a withdrawal where funds were available. Bank documents titled, "...Your Business Advantage Checking, Trust Account 1" dated 6/1/15 to 6/30/15, indicated the beginning balance on June 1, 2015 was $25,694.05. The document indicated a transfer to account **** (O/AD's business account) of $20,000 on 6/24/15. Bank documents titled, "Deposits and other Credits" indicated a transfer of $20,000 was made to account **** (O/AD's business account) dated 6/24/15. Bank document titled, "Resident Trust Account 1" dated 8/1/15 to 8/30/15, indicated a service fee of $35.00 had been applied to the account for an overdraft fee on 8/13/15. On 8/18/15 an online transfer from Resident Trust Account 2 to Resident Trust Account 1 was made in the amount of $5,000. On 5/18/16 at 4:55 p.m., during an interview, Resident 53's Public Guardian (PG) stated Resident 53 expired 6/25/15. The PG stated the facility did not provide trust account statements or an accounting of Resident 53's trust fund to her. The PG stated a check dated March 8, 2016 for $1,195.35 was returned to the Public Guardian's office in March 2016, more than 30 days after the resident's death. California Audits and Investigations Financial Audits Branch document titled, "Summary of Findings" (a report summary of the facility trust account audit, period of review 1/1/15 to 2/29/16) conducted in March 2016, indicated under Finding 7, "[Resident 53] expired on 6/25/15 with a trust fund balance of $1195.35. The trust funds have not been returned to the patient or the patient's representative." It further stated under Recommendations, "The provider should have appropriate controls in place to ensure that the clients' trust fund is being handled properly. The trust fund monies should be made available...within 30 days of the date of death. The patient/representative should be refunded..." Review of website www.Medicare.gov, undated, titled, "What Are My Rights and Protections in a Nursing Home" indicated "...The nursing home must allow you access to your bank accounts, cash and other financial records. The nursing home must have a system that ensures full accounting for your funds and can't combine your funds with the nursing home's funds. The nursing home must protect your funds from any loss...If a resident with a fund passes away, the nursing home must return the funds with a final accounting to the person or court handling the resident's estate within 30 days." Review of an undated letter addressed to "Nursing Home Administrator Program," date stamped received 5/25/16, and signed by the O/AD indicated, "We began borrowing money just to stay open and pay staff. At one point in May [2015] we were not able to meet our payables and payroll and I made the Decision to Borrow the money from the Residents Trust Account...I knew that this was wrong but I made the decision." Therefore, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property when the O/AD withdrew money without permission from resident trust accounts, including Resident 53, and diverted the funds to his business account in order to pay the bills of his personal business. This violation resulted in the wrongful use, without consent, of Resident 53's personal funds entrusted to the facility, intended for the immediate benefit of the resident only, including meeting Resident 53's wants and needs and improving the resident's quality of life. These violations, either separately or jointly, had a direct or immediate relationship to Resident 53's, health, safety or security, and therefore constitutes a Class "B" Citation. |
| 050000061 |
SAMARKAND SKILLED NURSING FACILITY |
050008714 |
B |
05-Apr-12 |
8QUW11 |
2905 |
F 223 483.13 (b)(b) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion."Involuntary seclusion" is defined as separation of a resident from other residents or from her/his/ room or confinement to her/his room (with or without roommates) against the resident's will, or the will of the president's legal representative. Emergency or short term monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used for a limited period of time as a therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the resident's needs. The facility did not comply with the above regulation by failing to protect a resident's right to be free from harm and involuntary seclusion. Resident A, who is dependent on staff for all activities of daily living including mobility, was involuntarily secluded when she was placed in a darkened, closed, dining room by CNA 1 in the early morning hours of September 27, 2009. Resident A was admitted to the facility on September 18, 2008 with diagnoses including Alzheimer's disease, depressive disorder, delusional disorder, and paranoid state (a person has delusions of persecution or grandeur). The comprehensive nursing assessment of March 2009 identified the resident had short and long term memory problems, was cognitively impaired, and exhibited symptoms of anxiety and depression. The assessment also identified that Resident A verbalized fears of being left alone and abandoned. Review of the facility's investigative report revealed a written statement by CNA 3 which stated the following incident involving Resident A. On September 27, 2009, around 3:30 a.m. CNA 3, went to get some hot water for tea/coffee. While walking in the hallway CNA 3 heard yelling coming from the closed dining room. When she entered the dark dining room she was surprised to find Resident A. The resident was crying and moaning, and had been incontinent. CNA 3 removed the resident from the dining room and reported the incident to her charge nurse. CNA 3 looked for the staff assigned to the resident's station and found CNA 1. When CNA 3 asked CNA 1 why the resident had been placed in the dark, closed, dining room alone, he replied "she keeps yelling."In a written statement CNA 1 verified that he had placed Resident A in the dining room because she was "screaming ." CNA 1 stated he "didn't want her (Resident A) to wake up the other residents" so he took the resident to the closed dining room.The facility was in violation of the above regulation by failing to protect Resident A from harm. On September 27, 2009, Resident A was involuntarily secluded when she was placed in a dark, dining room alone by C NA 1. This violation had a direct relationship to the health, safety and security of the resident. |
| 050000061 |
SAMARKAND SKILLED NURSING FACILITY |
050008727 |
A |
19-Jan-12 |
70V011 |
5179 |
F-323 483.25 (h) (h) Accidents - the facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.The facility failed to provide adequate supervision and assistance devices to prevent an accident. Resident A, who was identified as a high risk for falls, experienced eight falls in twelve months (from March 2010 through March 2011). The facility failed to reevaluate the effectiveness of provided interventions, provide increased supervision and implement new interventions, in an effort to protect the resident from injury and harm related to continued accidental falls. As a result, on March 24, 2011, Resident A fell in her room and sustained multiple life threatening injuries including a subdural hematoma, a fractured spine, and facial fractures.Resident A was admitted to the facility on March 25, 2009 with diagnoses that included dizziness, muscle weakness, low blood pressure, osteoporosis, and difficulty walking.A plan of care for the resident's risk of falls was developed upon admission. The facility identified that the resident was at risk for fall due to her history of falls, declining mobility and balance, an unsteady gait, use of psychotropic medications, poor safety awareness, and the resident's behavior of not consistently requesting assistance as needed.Interventions included: instructing the resident to use hand rails and ambulatory assist devices to maintain balance, keep the area free of obstructions, monitor for fatigue and side effects of medications (drowsiness, loss of coordination, fatigue, mental slowness, confusion) and remind the resident to call for assistance before getting out of bed, before going to the toilet.The most recent comprehensive nursing assessment, dated June 26, 2010, revealed Resident A had poor short term memory, required limited assistance of one staff to transfer from bed to chair, walk in her room, dress, and use the toilet. Resident A required partial support for balance, had an unsteady gait, and used a walker for support while ambulating.Resident 5 continued to experience accidental falls. Between March 26, 2010 and March 24, 2011, the resident fell eight times. There was no documentation to indicate the facility reevaluated the resident's high risk needs, and attempted to implement additional safety interventions and increased supervision, on an ongoing basis, to protect the resident from injury and harm related to continued falls.On March 24, 2011, Resident 5 experienced an eighth fall within a twelve month period of time, sustained significant life threatening injuries and required hospitalization. Nurses' notes dated March 24, 2011 at 8:40 p.m. stated "Found resident at 15:20 (3:20 p.m.) on the floor outside the door bathroom half way sitting position with the face down, her eyeglasses on the floor with her lens broken, noted a hematoma (an accumulation of blood under the skin related to injury) lower right eyelid, laceration (cut) above right eyebrow, skin tear right shoulder, alert and able to verbalize." The resident was transferred to the acute hospital for evaluation and admitted for treatment of a subdural hematoma, a fractured spine and multiple facial fractures. On March 28, 2011, Resident 5 was readmitted to the facility, with an order for "comfort care only." The resident expired April 3, 2011, ten days after her fall. Documentation on the physician's discharge summary of April 12, 2011 stated "Death secondary to fall with head injury." A concurrent review of the electronic and hard copy of the resident's record revealed no documentation to indicate fall prevention interventions were consistently evaluated and additional safety measures, such as the use of a tab alarm or bed sensor alarm, were implemented for the high risk resident.Interview with the clinical coordinator on November 17, 2011 at 3:45 p.m. revealed that the determination of the possible use of a tab alarm would be if the resident "had poor balance and was declining in condition. Or, had a history of falls." When asked if Resident 5 had either a tab alarm or bed sensor alarm, he stated, "No. She did not, from what I found in the chart." When asked if the plan of care had been revised when current interventions were not effective in preventing additional falls, he verified that it had not been. The clinical coordinator added that Resident 5 would have been a candidate for a tab and bed sensor alarm to alert staff when she got up, and did not call for assistance. The facility failed to reevaluate the effectiveness of provided interventions and failed to implement additional safety interventions to protect the resident from injury and harm related to the resident's repeated falls. As a result, Resident A continued to experience accidental falls, and on March 24, 2011, experienced a fall sustaining life threatening injuries including a subdural hematoma and a fractured spine.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. |
| 050000053 |
SANTA MARIA CARE CENTER |
050010171 |
A |
20-Feb-14 |
71G211 |
2414 |
CFR 483.25(h)(2) The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents.The Department determined the facility failed to provide adequate supervision and assistance to prevent an accident to Resident A. The facility failed to implement supervision and assistance during eating. These failures resulted in Resident A dipping fingers into hot coffee, resulting in thermal burns requiring emergency and on-going treatment. The family opted not to continue aggressive treatment, placed Resident A on Hospice. Resident A expired. The death certificate listed history of unwitnessed immersion burn of right hand as an underlying cause of death.Resident A was an 86 year old male, admitted to the facility on July 26, 2010 with diagnoses including dementia. A comprehensive assessment dated August 6, 2010 revealed Resident A required two-person assistance for ambulation, positioning, bed mobility and transfers. Resident A was moderately impaired in decision making and had periods of altered perception or awareness of surroundings. Resident A needed one-person assist with eating. Resident A's functional/rehabilitation care plan indicated Resident A required supervised, limited assistance with eating.A review of the acute hospital emergency department report dated September 26, 2010 indicated Resident A admitted dipping his fingers in coffee. Per the emergency department record, Resident A had burns on the right hand surrounding the third finger and the second and fourth finger with blistering that were filled with clear fluid. During an interview on June 21, 2012 at 4 p.m., a certified nursing assistant (CNA 3) explained when she walked into Resident A's room to assist him with eating, the meal tray was already in front of Resident A and the coffee had already been spilled. During an interview on June 22, 2012 at 3:45 p.m., the director of nursing (DON) confirmed Resident A was left unattended, dipped his hand into a cup of hot coffee, and received thermal burns.The facility's failure to provide necessary supervision, as previously assessed while eating and leaving Resident A unattended, resulted in Resident A's transfer to the hospital for treatment of thermal burns.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. |
| 050000053 |
SANTA MARIA CARE CENTER |
050011093 |
A |
18-May-15 |
Q4SY11 |
2959 |
CFR 483.25 (H) Accidents. The facility must ensure that - (2) Each resident receives adequate supervision and assistance devices to prevent accidents.The Department determined the facility failed to provide adequate supervision to prevent injury for Resident A, who got up from bed, walked unassisted, and fell face down onto the hallway floor. As a result, Resident A sustained multiple facial fractures. Resident A was a 74 year old female, admitted to the facility with diagnoses including dementia, brain tumor, and muscle weakness.The admission nursing assessment, dated 3/7/14, identified, Resident A had numerous falls prior to admission. A comprehensive assessment, dated 3/13/14, revealed, Resident A has memory problems, with impaired decision making skills, and required assistance for walking. A care plan, dated 3/7/14, titled, "Falls", included interventions to have Resident A's bed in the lowest position and a tab alarm. The tab alarm was discontinued on 3/9/14 because Resident A could remove it and a bed alarm (caregivers can hear an alert when a resident is about to get up from a bed) was implemented instead.Review of a nurse's note, dated 3/7/14, 3/8/14, and 3/9/14, revealed, Resident A needed to be reoriented and redirected due to confusion. Resident A had gotten out of bed unassisted several times, detached her tab alarm, and then walked around. Resident A had to be monitored closely for safety due to attempts to take the bed alarm off. During an interview on 10/2/14 at 6:30 a.m., certified nursing assistant (CNA) indicated, she was at the nurses' station when a bed alarm sounded. CNA was approaching Resident A's room at room 7 when CNA witnessed Resident A standing at the door of her room (room 7), then fell face down into the floor of the hallway.A concurrent observation and interview, on 10/6/14 at 12:30 p.m., revealed, the response time for staff to get from the nurses' station to room 7 was 16 seconds. The administrator confirmed, based on the time for staff to respond to Resident A's bed alarm in room 7, it was not an adequate intervention for preventing Resident 1's injury related fall. The facility had not explored moving Resident A closer to the nurses' station. During an interview on 10/6/14 at 12:45 p.m., the administrator confirmed, beds in rooms 10 and 11 were available on 3/10/14 and Resident A could have been placed closer to the nurses' station providing increased monitoring by staff and a quicker response to an alarm when Resident A attempted to get out of bed unassisted. Review of the hospital emergency room report, dated 3/13/14, revealed, Resident A sustained the following injuries secondary to falling: right side forehead bruise, cut lips, bilateral nasal bone fractures, fracture of the nasal bony septum, fractured left cheek bone.This presented imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 050000002 |
SHORELINE CARE CENTER |
050011736 |
A |
06-Apr-16 |
SLGS11 |
4610 |
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 Department determined, the facility failed to provide pain management when Resident A's pain medications were abruptly discontinued due to lack of insurance coverage. As a result, Resident A suffered withdrawal symptoms and pain manifested by self-inflicted injuries and behavioral changes. Resident A was a 38 year old female, with diagnoses including infantile cerebral palsy (a congenital disorder of movement, muscle tone or posture) and psychosis (a mental disorder characterized by disconnection from reality). Resident A has severely impaired cognition (mental awareness) and needed extensive assistance with activities of daily living.Review of physician's orders revealed, Resident A has been on two narcotic pain medications, morphine 5 milligrams (mg) every two hours as needed for moderate pain since 9/26/14 and methadone 5 mg every 12 hours routinely since 10/29/14 for pain management. On 6/18/15, both narcotic pain medications were abruptly discontinued due to lack of insurance coverage. Abrupt discontinuation of methadone can cause severe withdrawal symptoms within 30 hours, such as muscle aches, pain, vomiting, cramps, and diarrhea for several days.During an interview on 7/20/15 at 4 p.m., Resident A's Developmental Center case manager (CM) indicated having followed Resident A's care for the last eight years. Resident A's behavior at the facility has been stable up to the time the methadone had been abruptly stopped. The CM stated, "the escalation is striking and some of these behaviors have not been seen in years and are actually a regression back to her days at the development center." Resident A has been crying, hitting and biting herself, was combative, attempting to get out of bed, and uncooperative with 1:1 staff. Resident A's arms, legs, and hips had multiple black and blue marks and her knees and hands were reddened from attempting to bite herself. Resident A has been agitated, holding her head, sneezing, and crying for no reason. During an interview on 7/17/15 at 3 p.m., Resident A's responsible party stated, during her visit on 6/23/15, "They [facility] took her off methadone cold turkey. I know when she is in pain she will start biting herself; she won't let you touch her; she would rather be by herself; she would not lay down; she was crying and she started scratching her skin. Even I, who can usually redirect her, but I couldn't. No one told me that her methadone was going to be reduced. I started asking questions and then I found out. I called her physician that same day and he said he was going to look into it." During an interview on 7/17/15 at 4 p.m. , LN 2 revealed, when methadone was discontinued on June 2015, Resident 4 started to bite herself and spit out her other medication.During an interview on 7/15/15 at 8:30 a.m. with 1:1 nursing assistant (NA 1) revealed, when Resident A's medication was changed in June 2015, Resident A kept holding her head saying her head hurts. Resident A was kicking; taking her clothes off, and became incontinent.During an interview on 7/16/15 at 9:30 a.m. with NA 2 revealed, when Resident A's medications were changed on June 2015, Resident A became really difficult. Resident A pulled her hair, hit the walls, and was unable to be redirected. During an interview and concurrent record review of Resident A's pain medications on 7/17/15 at 9 a.m., the director of nurses (DON) confirmed, she was not aware of any tapering (slowly reducing the dose) of the methadone.During an interview on 7/16/15 at 9:45 a.m., the facility pharmacist consultant (PC) confirmed, there was no medication review done by the PC when the methadone was discontinued on 6/18/15. PC indicated, tapering the methadone is recommended, rather than abruptly discontinuing.The facility should know or should have known, discontinuing methadone abruptly can cause severe withdrawal symptoms and regression to previous physical symptoms and behavioral problems. The facility failed to refer and obtain tapering recommendations from their pharmacy consultant. This facility action had caused Resident A to suffer withdrawal symptoms and pain manifested by self-inflicted injuries and behavioral changes. This presented imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 050000248 |
ST JOHNS PLEASANT VALLEY HOSPITAL D/P SNF |
050011791 |
B |
30-Oct-15 |
WFPI11 |
2570 |
CFR 483.12(b)(3) Permitting Resident to Return to Facility A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services.The Department determined the facility failed to follow their policy on readmission for Resident 1 when the facility did not readmit Resident 1 following hospitalization which exceeded the bed hold period. Resident 1 was discharged to the acute hospital on 4/5/15 and remained in the acute hospital up to the time of the complaint investigation conducted on 9/10/15. Resident 1 was transferred to the hospital due to hypoxemia (low oxygen in the blood) and pneumonia (infection of the lungs). Resident 1 had a tracheostomy tube (surgical opening through the trachea to allow passage of air) and a gastrostomy tube (surgical opening through the abdominal wall into the stomach for nourishment). Review of comprehensive assessment dated 2/25/15, revealed Resident 1 had no problem with memory and Resident 1 required total assistance with activities of daily living. During an interview on 7/2/15, at 3 p.m., the Director of Nursing (DON) explained, the hospital contacted the facility that Resident 1 was ready for readmission on 4/20/15 and 6/5/15. The facility had stated multiple reasons why they could not readmit the resident including "no physician would accept the resident."Review of the facility's daily census on 4/20/15 and 6/5/15, indicated a male bed was available. Resident 1 was not readmitted. During an interview on10/15/15 at 10:55 a.m., the acting DON (former DON no longer employed) confirmed, Resident 1 was still in the hospital.During an interview on 10/15/15 at 10:55 a.m., the patient safety and accreditation officer (PSAO) explained that the facility provided a list of physicians and alternate facilities to resident's responsible party but all had been refused. The facility was unable to provide documentation and evidence of the responsible party refusal to available physicians to care for Resident 1. The facility failed to follow the facility's policy on readmission for Resident 1 which resulted in violation of the resident's right to readmission as required by law. The above violation has a direct or immediate relationship to the health, safety, or security of the resident. |
| 050000053 |
SANTA MARIA CARE CENTER |
050012369 |
B |
22-Sep-16 |
MD1D11 |
2697 |
California Health and Safety Code 1418.91 (a) (b)-Failure to Report (a) A long-term care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. The Department determined the facility was in violation of the above statute by its failure to report to the Department an allegation of abuse immediately or within 24 hours. Review of admission record for Resident 1 indicated diagnoses including dementia (a gradual decline of mental abilities) and inability to move left side of the body. A comprehensive assessment dated 11/17/15 indicated Resident 1's cognition (mental processes of gaining knowledge and comprehension) was severely impaired with "periods of screaming and wheeling herself while unaware of the surroundings." Resident 1 required extensive assistance with activities of daily living like eating, bathing, dressing, and grooming. Review of admission record for Resident 2 indicated diagnoses including high blood sugar and left side weakness. A comprehensive assessment dated 3/26/16 indicated Resident 2's cognition was intact, required no staff assistance for moving about the facility in a wheelchair. Review of Resident 2's Nurse's Notes dated 4/9/16 indicated at 6:30 p.m., a certified nurse assistant (CNA 1) informed licensed nurse (LN 1) that CNA 1 removed Resident 2 from Resident 1's room. CNA 1 explained being summoned to Resident 1's room by Resident 1's roommate, Resident 3. Resident 3 made "Hand gestures of calling and pointing her finger in the direction of her roommate (Resident 1)." CNA 1 "Caught (Resident 2) by surprise, with his wheelchair positioned too close to the bedside of (Resident 1)." CNA 1 asked Resident 2 what he was doing in the room. Resident 2 replied, "Visiting (Resident 1)." Review of the Nurse's Note dated 4/9/16 at 6:45 p.m. written by LN 1 indicated, the director of nursing (DON) was called and informed of the incident. Per the Nurse's Note, the DON advised LN 1 to inform the facility administrator. The Nurse's Note indicated, "Resident 2 wheeled himself close to Resident 1's bed, placed his hand under the covers. I'm not sure of where exactly his hand was but he was enjoying what he was doing and that lasted for 2 minutes or so until the aide came and pulled him out of the room. "The note indicated Resident 1's responsible party was notified of the incident on April 9, 2016 at 9 p.m." During an interview on 5/4/16 at 12 p.m., the Administrator explained, he did not report the allegation of abuse within 24 hours to the Department. |
| 050000070 |
SIMI VALLEY CARE CENTER |
050013213 |
B |
19-Jul-17 |
41MT11 |
4273 |
CFR 483.15(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following:
(i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident-
The Department determined the facility was in violation of the above regulation when it failed to permit Resident 1 to return to the facility upon transfer to an acute care hospital's Emergency Room (ER) on XXXXXXX17.
A review of the facility's admission policy on 5/16/17 under "Admission, Transfer and Discharge" indicated "the facility must permit each resident to remain in the facility, and not transfer or discharge unless-
i) The transfer or discharge is necessary for the resident's welfare, and the resident's needs cannot be met in the facility;
ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
iii) The safety of individuals in the facility is endangered;
iv) The health of individuals in the facility would otherwise be endangered;
v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to the facility, the facility may charge a resident only allowable charges under Medicaid; or
vi) The facility ceases to operate."
Record review on 5/16/17 indicated Resident 1 was admitted to the facility on 8/31/16 with diagnoses including Atrial Fibrillation (irregular heart beat), depression and stroke. The facility's "Resident Transfer Record," dated 1/18/17 indicated Resident 1 was transferred to an acute care hospital (ER) due to "Right eye blood shot."
A review of the acute care hospital's ER Physician Note, dated 1/18/17 at 9:48 p.m., indicated it was the physician's intent to discharge Resident 1 back to the facility, however, the facility's administrators refused to accept Resident 1 back. The note also indicated a "Charge Nurse spoke to the facility at length."
Review of the ER nurses' note, dated 1/18/17 at 10:39 p.m., indicated a nurse spoke with the facility, and the facility "stated they did not want to accept the resident back." The ER nurse informed the facility staff they needed to work that out with the daughter because Resident 1 was cleared for discharge from the acute care hospital.
Review of another ER nurses' note, dated 1/18/17 at 11:01 p.m., indicated the nurse spoke with the facility's administrator, who stated if the hospital ER sent Resident 1back to the facility, Resident 1 would not be permitted admission.
Further review of the acute care hospital's clinical record for Resident 1 revealed a Case Manager/Social Worker note, dated 1/19/17 at 1:45 p.m., indicated the Case Manager spoke with the facility, and the facility refused to permit Resident 1 to return to the facility.
Another hospital Case Manager/Social Worker note, dated 1/20/17 at 2:00 p.m., indicated the Case Manager had spoken with the facility's Administrator who indicated he would not accept Resident 1 back into the facility.
During an interview on 5/16/17 11:30 a.m., Resident 1's daughter confirmed Resident 1 was denied readmission back into the facility after the residents ER visit on 1/18/17. As a result, Resident 1 was discharged from the ER to a different facility which was out of the resident's residing county.
During an interview on 5/16/17 at 2:30 p.m., the facility's Administrator confirmed denying Resident 1 readmission to the facility. The Administrator stated "the management team made an executive decision not to permit the resident (Resident 1) back to the facility."
The facility's failure to readmit Resident 1 caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the resident. |
| 060000029 |
ST. ELIZABETH HEALTHCARE CENTER |
060009176 |
B |
22-Mar-12 |
VE5H11 |
6604 |
72311 (a) (1) (B) Nursing Service-General (a) Nursing service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at least the following: (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.On 2/27/12 at approximately 1000 hours, Patient A was found on the floor in the bathroom when Certified Nursing Assistant (CNA) 1 left Patient A alone in the bathroom to organize his room and make his bed. CNA 1 stated she heard a noise coming from the bathroom, hurried into the bathroom and found Patient A on the floor. Patient A sustained a subdural hematoma (bleeding in the brain) and an orbital (eye socket) fracture. The facility failed to ensure Patient A, who is a high risk for falls, was closely supervised while he was in the bathroom, which resulted in Patient A falling off the toilet. Health record review for Patient A was initiated on 3/6/12. Patient A was admitted to the facility on 1/6/09, with diagnoses including cerebral vascular accident (stroke) with right side hemiparesis (weakness) and dementia. Review of Patient A's Minimum Data Set (MDS) dated 12/29/11, showed he has short and long term memory impairment.Review of Patient A's Care Area Trigger (CAT) worksheet shows he does not have the capacity to understand and make decisions and is at risk for fall and injury.Review of Patient A's Fall Risk Assessments dated 9/29/11, and 12/29/11, showed a score of 18 (if the total score is 10 or greater, the patient should be considered as having a high potential for falls). Review of Patient A's physician's orders showed an order dated 1/21/11, for Patient A to have a personal alarm when in bed to remind him not to get up unassisted, and an order dated 4/18/11, for the use of a non-release seat belt when in a wheelchair, due to dementia and poor safety awareness and falls.Review of Patient A's Physical Restraint Update dated 9/29/11, showed to continue with the use of a non-release seat belt when up in a wheelchair and personal alarm in bed due to poor safety awareness related to dementia.Review of Patient A's care plan dated 12/29/11, to address his Activities of Daily Living (ADL) function, showed he needs extensive assistance with transfers and toileting needs. No care plan was developed for Patient A's need for direct supervision on the toilet. Review of Patient A's Interdisciplinary Progress Note dated 1/24/12, showed Patient A needs a non-release seat belt when in a wheelchair and a personal alarm when in bed to alert the staff of Patient A getting up unassisted.Review of Patient A's ADL worksheet for dates 2/1/12 through 2/27/12, showed Patient A is disoriented and requires the use of a (seat) belt during the morning shift.Review of Patient A's psychiatric Progress Note dated 2/23/12, shows he is easily distracted because of a short attention span, excited, irritable and labile. He has bizarre behavior, associations are not intact, thinking is illogical and thought content is inappropriate.Review of Patient A's Incident/Accident Investigation Report dated 2/29/12, showed a condition which may have contributed to the incident/accident as Patient A leans forward at times and is confused. The results of the investigation showed Patient A was sitting in the bathroom while CNA 1 was outside the bathroom making his bed. CNA 1 found Patient A on the floor with a 0.5 centimeter (cm) x 4 cm laceration above his right eye. Interventions identified to minimize the potential of reoccurrence included the use of a shower chair belt.Review of Patient A's Post Fall Assessment dated 2/27/12, showed a recommendation to prevent further falls for Patient A to have close monitoring by the nursing staff.Review of Patient A's emergency room report dated 2/27/12, showed his right eyebrow laceration was approximately 8 cm in length and required a total of 40 sutures to repair.Review of Patient A's computerized tomography (CT) of the brain without contrast report dated 2/27/12, showed a minimal subdural hematoma and a comminuted fracture of the right maxillary sinus walls and a fracture of the right lateral orbital wall.Review of Patient A's CT of the orbit without contrast report dated 2/27/12, showed a non-displaced fracture of the lateral wall of the right orbit, total opacification of the right maxillary sinus with fractures involving the floor, medial, lateral and anterior walls.During an interview on 3/6/12 at 1425 hours, CNA 1 stated Patient A is disoriented at times and dependent on staff for all his ADLs. She stated Patient A requires two staff members to assist in his bed mobility and transfers. CNA 1 stated on 2/27/12 at approximately 1000 hours, she transferred Patient A from the shower chair to the toilet and left him in the bathroom alone, to make his bed. She stated she heard a loud noise and found Patient A face down on the floor, bleeding from his right eyebrow.During an interview on 3/6/12 at 1440 hours, CNA 2 stated Patient A was disoriented and needs assistance from two staff members for bed mobility and transfers.During an interview on 3/6/12 at 1445 hours, the Restorative Nursing Assistant (RNA) stated Patient A needs assistance from two staff members for bed mobility and transfers and is totally dependent on the staff for all his ADLs. He stated on 2/27/12 at approximately 1000 hours, he heard CNA 1 yelling for help inside Patient A's room. The RNA stated Patient A was lying on the floor, had blood on his gown and was bleeding from his nostril and right eyebrow. He stated Patient A was nonresponsive and looked shocked.During an interview on 3/6/12 at 1610 hours, LVN 1 stated Patient A is confused and unable to make his needs known. He stated Patient A needs two staff members for bed mobility and transfers. LVN 1 stated Patient A wears a seat belt when he is up in a wheelchair because Patient A sometimes slides down in the seat. He stated Patient A has attempt to climb out of bed and wears a personal alarm while he is in bed to alert the staff if he attempts to climb out of bed unassisted.During an observation on 3/6/12 at 1350 hours, Patient A was asleep in his bed. His right eyebrow had multiple sutures in place. The right side of his neck and right eyebrow were ecchymotic (black and blue). The facility's failure to develop a car plan to address Patient A's need for direct supervision while toileting had a direct or immediate relationship to the health, safety, or security of the patient. |
| 060000026 |
Seal Beach Health and Rehabilitation Center |
060010117 |
B |
26-Aug-13 |
L87E11 |
4545 |
483.75(l)(3), 483.20(f)(5) A facility may not release information that is resident-identifiable to the public. The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. The facility must safeguard clinical record information against loss, destruction, or unauthorized use. The facility failed to ensure 56 residents' personal and confidential medical privacy was maintained. Facility documents identifying 56 names of residents, health conditions, associated treatments and response to various treatment were found in a trash can located in a public area, inside the facility, by an unauthorized person. Failure to safeguard residents' personal health information violates the resident's right to privacy. Findings: According to the facility's policy and procedure (P & P) titled "Confidentiality/Protection of Patient Information" dated 2/1/96, the facility will maintain confidential treatment of the resident's medical records, and records are safeguarded to protect the confidentiality of information. On 7/30/13, the Department received a complaint containing 65 pages of facility documents titled "Pressure Sore Management Record" dated 5/2009 through 8/2009. The documents contained 56 different residents' names, room numbers, pressure ulcer site(s), treatments and response to care.On 8/7/13 at 1010 hours, a telephone interview was conducted with the complainant. The complainant stated was visiting the facility and observed a trash can, which is located in a public area, filled with folders. The complainant stated the room where the trash can is located, is frequently used by visitors. The complainant stated he/she took a handful of the discarded folders home for personal use; however, later discovered they contained facility documents (described above). On 8/7/13 at 1300 hours, an interview was conducted with the Administrator. He was advised of the unauthorized person having access to facility confidential documents, found in a trash can inside a public area. When asked to identify how facility documents could have been placed in a trash can and accessed by unauthorized persons, he was unable to do so. The Administrator was asked what the facility's policy is for destroying confidential documents containing resident's health information. He stated the facility uses secured shredder bins to collect confidential information, and a service is contracted to pick up the documents for shredding.On 8/7/13 at 1315 hours, an interview was conducted with the DON. When asked about Pressure Sore Management Record forms, the DON stated the treatment nurse(s) complete these records weekly and give them to her for review. The DON stated she stores the records for one year, and then will forward them to Medical Records for storage or destruction. The DON said she does not have any old pressure ulcer management records in her office. When asked if she knew how the documents could have been placed in an area accessed by unauthorized persons, she said she didn't know.During an interview with the ADON conducted on 8/7/13 at 1335 hours, the ADON stated only the current Pressure Sore Management Records (April 2013 to present) are kept in the office. She stated records prior to April 2013 were maintained by the previous ADON. She stated documents containing confidential resident information are shredded.On 8/7/13 at 1345 hours, an interview was conducted with the Medical Records Director. When asked if there is a facility policy and procedure about the storage and destruction of confidential resident information, he stated, "No." He stated the standard of practice for destroying any confidential documents is to place it in the shredder box.On 8/7/13 at 1420 hours, an interview was conducted with the DSD. The DSD stated all newly hired employees receive training to maintain resident privacy, which includes using shredder boxes to destroy documents.On 8/18/13, the Department received a written declaration dated 8/17/13, from the complainant. The declaration shows the complainant found facility documents in a trash container located in a room that is frequented by the public. Specifically, the declaration described how the complainant found the confidential documents and what the documents contained (as described above).The above violation has a direct relationship to the health, safety or security of residents. |
| 060000053 |
SEA CLIFF HEALTHCARE CENTER |
060011418 |
B |
29-Apr-15 |
D8MQ11 |
12759 |
F309 G dual enforcement to Class B citation (SP) From Survey 3-11-15 F-309: Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident 12 had a history of chronic and severe pain requiring fentanyl (a long term opioid pain medication) 100 mcg daily via a transdermal patch applied to the skin. There was a nine day delay in receiving the refill order for fentanyl which caused Resident 12 to experience excruciating pain. As a result of the pain, Resident 12 did not want to move which caused an existing pressure ulcer to worsen. Resident 12 was assessed be admitted with a Stage II pressure ulcer to his right buttock.Findings: Clinical record review for Resident 12 was initiated on 3/4/15. Review of the Admission Record showed Resident 12 was admitted to the facility on 1/17/15, with status post left hip fracture requiring surgical repair. Resident 12 had a history of chronic pain and poliomyelitis. Resident 12 was allergic to Ultram (used for pain) and Vicodin (narcotic). Review of a care plan problem to address Resident 12's pain dated 1/18/15, showed the resident had chronic pain due to polio. The interventions included to administer pain medication as ordered, respond immediately to complaints of pain, and evaluate the effectiveness of the interventions. Review of the H&P dated 1/20/15, showed Resident 12 had the capacity to understand and make medical decisions. In addition, the resident was assessed to have a surgical incision to his left hip, measuring 15 cm long with 28 staples.The MDS dated 1/24/15, showed Resident 12 was alert, oriented, and capable of making his needs known. He required assistance with his ADL care including daily hygiene care and transfers.On 1/22/15, Resident 12 was assessed to have a Stage II pressure ulcer to his right buttock area. On 1/30/15, Resident 12's pressure ulcer was assessed to have deteriorated to a Stage III. On 3/6/15 at 0900 hours, an interview with Resident 12 was conducted. Resident 12 stated he was admitted to the facility in January 2015, after being hospitalized due to a fractured left hip and knee he had sustained from a fall.He stated he had a history of chronic pain due to having polio as a child. He stated he had been using fentanyl 100 mcg for six years, including his recent hospitalization to help control his pain. Resident 12 stated he experienced pain when he was first admitted to the facility; however, his pain got a lot worse to the point it was excruciating. He stated the fentanyl patch that was applied when he was admitted had expired and was not replaced until nine days later. Resident 12 stated he kept asking the nurses and the RNP for a new fentanyl patch. He stated he was prescribed oxycodone for breakthrough pain and was having to take a lot of it; however, it was not as effective as the fentanyl had been. Resident 12 stated if anyone touched his bed or the pillow (under his knee), he would experience excruciating pain. Resident 12 also stated he developed a new pressure ulcer since he was admitted to the facility. He stated he knew he was supposed to turn (relieve pressure) to help heal the pressure ulcer, but it hurt to move and he had told staff not to move him.Resident 12 stated a PA who specialized in pain control came to see him and increased the dosage of oxycodone to 10 mg, but it still did not control his pain. The resident stated he was getting physical therapy, but there were times he could not participate very much because of his pain.Lexicomp (an online pharmacy website used by healthcare professionals), identified fentanyl as a transdermal opioid pain patch. The medication is released into the skin at a nearly constant rate where it is accumulated by the body to provide pain relief. This results in a gradual increase in serum blood concentration over the first 12-24 hours, followed by fairly constant concentration for the remainder of the dosing interval (up to 72 hours). The patch should be changed every 72 hours for effective pain relief.Review of the facility's P&P titled Physician's Orders, Telephone Orders and Recapitulation Process dated 11/2007, showed when a resident is admitted to the facility and the licensed nurse is not able to implement a medication order due to the order needing to be clarified, the physician needs to be contacted for authorization. If the physician does not respond within 24 hours, the licensed nurse will notify the DON who will involve the facility's Administrator and/or Medical Director.Additional clinical record review for Resident 12 was conducted. Review of the physician's orders showed Resident 12 was prescribed the following pain medications:* On 1/17/15, fentanyl 100 mcg patch to be applied every 72 hours, starting on 1/18/15.* On 1/17/15, oxycodone-acetaminophen (Percocet, a narcotic) 5-325 mg one tablet PO every four hours as needed for moderate-severe pain.* On 1/18/15, Ultram 50 mg one tablet PO two time a day for pain management. However, this medication was discontinued on 1/18/15 at 1224 hours, due to the resident's allergy.* On 1/22/15 at 1130 hours, discontinue Percocet 5-325 mg and start Percocet 10-325 mg 1 tablet PO every four hours as needed for severe pain.Review of the MAR for January 2015, showed on 1/18/15 at 0900 hours, the licensed nurse documented Resident 12's fentanyl patch was not administered.Review of a pharmacy delivery slip dated 1/18/15, showed the facility had received only two fentanyl patches for Resident 12 on 1/18/15 at 2200 hours.Review of the Controlled Medication Count Sheet showed the first Fentanyl patch was applied to Resident 12 on 1/18/15 around 2200 hours.Further review of the January 2015 MAR showed on 1/18/15 at 2100 hours, the resident was administered Percocet for a pain level of 7/10.Review of the Pain Management Flowsheet showed the facility's pain intensity scale identified "0 = no pain, 5 = moderate pain and 10 = worst possible pain." Review of Resident 12's Pain Management Flowsheet showed from 1/19/15 through 1/31/15, showed Resident 12 consistently rated his pain level as moderate to severe (6 to 9 out of 10).Staff documented Resident 12 was administered Percocet or oxycodone 26 times from 1/19/15 through 1/31/15. Review of the Progress Note dated 1/19/15 at 1045 hours, showed the RN documented Resident 12 complained of "severe" left hip pain which was not relieved with Percocet. The resident identified pain intensity as "7/10." The resident was given oxycodone which was "helpful."Review of the Progress Note dated 1/19/15 at 2208 hours, showed Resident 12 complained of severe pain which was not relieved by oxycodone.Review of the PT Evaluation and Plan of Care dated 1/19/15, showed the PT documented Resident 12's pain was 7/10 at rest. The PT documented the resident did not attempt to self- propel his wheelchair due to left hip pain. On 1/21/15, according to the January 2015 MAR, Resident 12 received the second Fentanyl patch.The PT's Progress Note dated 1/21/15, showed although Resident 12 was premedicated with breakthrough pain medication prior to PT, the resident complained of constant pain to the left lower extremity which limited his ability to move.Review of the Physician's Progress Note dated 1/22/15, showed the pain management the PA documented indicated Resident 12 stated he was having pain from the left hip and knee and his pain was not currently well controlled. The Progress Note further showed the pain medications were only minimally helping control his pain. The PA increased the dose of oxycodone from 5 mg to 10 mg. There was no documented evidence the DON or Medical Director were notified about the delay of fentanyl patches being filled.On 1/24/15, the January 2015 MAR identified a note from the licensed nurse which showed a new fentanyl patch was not applied. There was no reason documented why a new patch was not applied as ordered.Review of the PT's progress note dated 1/26/15, showed Resident 12 complained of increased knee pain and he felt the pain medications were no longer helping him. The PT documented Resident 12 was very guarded and protective of anyone touching his left lower extremity. The PT documented he advised the nurse of Resident 12's pain.The PT's progress note dated 1/28/15, showed Resident 12 complained of pain at 8 out of 10 to his left lower extremity. The PT documented Resident 12's pain had progressively gotten worse since his admission, particularly to his knee. Review of the clinical record showed the following Progress Notes entries: * On 1/28/15, the pharmacy was called regarding Resident 12's fentanyl patch refill. The note showed the pharmacy needed authorization from the resident's physician. Staff documented the licensed nurse requested the pharmacy follow-up with the physician as soon as possible due to the resident's complaints of pain.* On 1/29/15, the RNP was visiting the facility and signed the required authorization form for the fentanyl patches and the form was faxed to the pharmacy. A note showed the medication would be delivered on 1/29/15 around noon.* On 1/30/15, the pharmacy was called again because the medication had not yet arrived.Review of the pharmacy delivery slip showed Resident 12's fentanyl patches were not delivered until 1/30/15 at 1030 hours.Review of the January 2015 MAR showed Resident 12 received a new fentanyl patch on 1/30/15, after the last patch was applied on 1/21/15, a nine day delay.Additional clinical record review found no documentation staff had followed their P&P and attempted to notify the DON or Medical Director regarding the delay of fentanyl patch being filled.On 3/9/15 at 0815 hours, an interview with the PT was initiated. The PT stated Resident 12 did have a lot of pain and did not want to get out of bed to participate in therapy. The PT stated he had to change the therapy treatments to adjust to Resident 12's pain until his pain was better controlled.On 3/9/15 at 0830 hours, an interview was conducted with RN 1. RN 1 confirmed Resident 12's had a fentanyl patch last applied on 1/21/15; however, a new patch was not applied until nine days later, on 1/30/15. She stated the pharmacy would only deliver two patches and needed written authorization from the physician for more fentanyl patches. The delivery for additional patches was not received until 1/30/15.On 3/9/15 at 1045 hours, during an interview with the DON, the DON stated she was not aware Resident 12 had a lapse in receiving fentanyl patches in January 2015. On 3/10/15 at 1100 hours, an interview with Pharmacist Consultant 1 was conducted. He stated fentanyl was a controlled narcotic and had strict guidelines about dispensing the medication. He stated the first two fentanyl patches were delivered to the facility on an emergency basis. He stated the physician must sign the authorization and fax it back to the pharmacy. No additional fentanyl patches could be delivered until the original authorization form was sent back to the pharmacy. In addition, a new order could not be filled until additional authorization was obtained. The Pharmacist Consultant stated he had faxed the authorization form on three occasions to the physician's office; however, no one responded to his requests. The Pharmacist Consultant confirmed fentanyl should not be abruptly discontinued due to the potential for withdrawals and inability to maintain pain control. He stated the oxycodone dose Resident 12 was receiving would not be effective in controlling his severe pain because oxycodone is not as strong as the fentanyl. On 3/11/15 at 1600 hours, an interview with the RNP was conducted. The RNP was asked about the delay in getting the fentanyl patches for Resident 12. The RNP stated she was the primary practitioner for Resident 12's care; however, the pharmacy was attempting to contact the physician, not her to obtain the written authorization form for fentanyl. She confirmed there was a significant delay in Resident 12 getting his fentanyl patches.On 3/11/15 at 1800 hours, a follow-up interview with Resident 12 was conducted. Resident 12 stated he had a long history of pain and really tried to postpone taking any breakthrough pain medication. He stated he would try not to move in order to prevent having to take the breakthrough medication. He stated he often waited until his pain became unbearable before requesting oral pain medication.Three attempts were made to interview Resident 12's physician; however, no return calls were received. These failures have a direct and immediate relationship to the health, safety or security of patients. |
| 060001314 |
SEA BRIGHT PLACE |
060011767 |
B |
02-Oct-15 |
9DX911 |
9904 |
Welfare and Institutions Code Section 4502(h) 4502: Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. On 7/24/15 at 1550 hours, the facility was visited regarding an ERI that was reported to the CDPH. Based on interview and facility document review, the facility failed to ensure Client 1 was free of physical harm by failing to ensure their P&P (Policy and Procedure) was implemented when the DCS (Direct Care Staff) used another consumer's bed to change the incontinence pad of Client 1 without raising the side rail and using an incontinence under pad. As a result, Client 1 fell out of the bed and injured her mouth.On 7/12/15, an ERI was received by the CDPH regarding Client 1 falling out of bed and had injured her mouth.On 7/15/15 at 1145 hours, the facility's QIDP was contacted regarding the ERI on Client 1. During the telephone interview, the QIDP stated Client 1 was sent to the hospital emergency room on 7/10/15 and x-rays were taken. The client's gums were swollen and would need a dental examination. The QIDP stated Client 1 would be seeing a dentist today for oral x-rays.On 7/16/15 at 0845 hours, the QIDP faxed a message to the CDPH regarding Client 1's visit to the dentist. The message indicated the following: the x-rays taken showed the teeth inside Client 1's gums but they were not clear enough to see the details of the roots of the teeth. The dentist had referred Client 1 to an oral surgeon and the QIDP was going to make an appointment for Client 1 to see an oral surgeon.The QIDP also faxed a copy of an undated P&P titled Using a Consumer Bed for Another Consumer. The QIDP stated the P&P is the same for all facilities owned by this company. The facility's undated P&P titled Using a Consumer Bed for Another Consumer, read in part: "During the PCP monthly visits or other events when consumers from the other houses are at ....(Facility 2's name), it may become necessary to utilize a consumer's bed to change another consumer. In order to prevent cross contamination and maintain a clean surface for all consumers the following procedures will be followed:..." The P&P also indicated that if the bed is to be used for another consumer for changing, the under pads and the fitted sheet should be removed and the mattress and bed should be wiped with a disinfecting wipes and allowed to dry. Once dried, unused under pads should be placed on top of the dry disinfected mattress, then place a clean sheet on top of the under pads and secure it under the mattress or use a fitted sheet.On 7/20/15 at 0935 hours and 1505 hours, a telephone call was made to the QIDP and a message was left to call the surveyor back.On 7/20/15 at 2000 hours, the QIDP called the surveyor and left a message, stating the appointment with the oral surgeon had been rescheduled for 8/4/15. On 7/24/15 at 1550 hours, the facility was visited to investigate the above ERI. On 7/24/15 at 1600 hours, DCS 1 was interviewed regarding the incident on 7/10/15 when Client 1 was in his care and fell from the bed. DCS 1 stated they were at a sister facility (Facility 2) where Client 1's physician was making a visit. DCS 1 stated Client 1 needed a change of her incontinence pad so he placed her on another consumer's bed. DCS 1 stated he had forgotten to get a blue Chux (incontinence under pad). However, when DCS 1 turned to get the Chux, Client 1 fell from the bed. When asked how he would usually prepare the bed when at another facility, DCS 1 stated he would put a blue pad (Chux) on the bed. At 1615 hours, the House Leader was interviewed and stated on 7/10/15, he helped DCS 1 transfer Client 1 to the bed and then left the room. At 1620 hours, DCS 1 was asked again how he would usually prepare the bed when at another facility. DCS 1 stated he would put a blue pad (Chux) on the bed. DCS 1 also stated that the facility had a policy to raise the side rails. He also stated the facility had another policy regarding changing of a female client in which a female DCS should be present. When asked if there was anything else that was required or needed to be done before changing a client on another client's bed, DCS 1 stated to put a blue pad (Chux) on the bed.At 1625 hours, the facility's QIDP stated everything about the incident on 7/10/15, regarding changing Client 1 was done incorrectly. The QIDP stated Client 1 was placed on top of the folded bedcover which was a satin type material. The blanket slid and Client 1 slid off the bed with the blanket.The QIDP stated all the facilities owned by this corporation followed the P&P titled Using a Consumer Bed for Another Consumer. The QIDP was informed of the concern that the DCS were not following the facility's P&P regarding keeping the client safe from falls and changing a client when at another facility. The QIDP agreed and stated the DCS took shortcuts. The QIDP stated the facility policy was to have a male and a female DCS/staff present when changing a female client and the female DCS/staff was to do the cleaning. The QIDP added the female DCS/staff was standing outside the door not assisting the client when the incident happened. The QIDP stated when a client was placed in bed, the client should be in the middle of the bed. Once the client was in the bed, the side rails should be up to prevent the client from falling out of the bed. The QIDP stated the DCS were not prepared by not having items they would need at the bedside for changing the client (ointment and wipes etc.). Review of the facility's SIR dated 7/15/15, showed the following: On 7/10/15 while at the sister facility, Client 1 needed to be changed. Client 1 was placed on another consumer's bed on top of a folded comforter to prevent cross contamination. DCS 1 was waiting for the female DCS to come in and change Client 1. DCS 1 decided to get the Calmoseptine (a multi-purpose moisture barrier that protects and helps heal skin irritations) ointment from Client 1's backpack by stepping away from the bed with his back towards the client. While in this position, DCS 1 heard a noise. DCS 1 turned back around and saw Client 1 on the floor with her face down with the folded comforter on top of her. Due to DCS 1 not putting the bed rail up, the folded comforter began to slide open, and Client 1 slid out of bed onto the floor.The SIR continued to indicate Client 1 was placed back on the bed. Client 1 was examined by the Nursing Supervisor and the following was identified: - There were bleeding from two upper teeth; - There was a cut on the middle part of the lower lip that measured 0.5 cm; - There were redness on two areas of the right bicep, measuring 2 cm and 1.5 cm;- There was redness on the left shoulder, measuring 3 cm by 2 cm; - There was redness on the left clavicle area, measuring 9 cm by 3.5 cm; - There was redness on the left axillary area, measuring 3 cm; - There was redness on the left knee, measuring 4.5 cm; - There was redness on the right elbow, measuring 8 cm by 4.5 cm; and - There was redness on the right knee posterior area, measuring 2.5 cm by 3 cm. The SIR further indicated that at 1135 hours, Client 1 was transported to the emergency room accompanied by the facility nurse. At the emergency room, the facility nurse noted a bruise on Client 1's chin that was turning purplish. Client 1 indicated she had hit her chin on the wheelchair as she fell to the floor. At the emergency room, x-rays of the bilateral knee, elbows, and the facial bones were done and no fractures were identified. Client 1 required no medical intervention and was discharged from the emergency room at 1615 hours. The SIR also showed Client 1 would be going to the dentist that weekend to have dental x-rays taken. It was also documented that Client 1 was at home with no complaints of pain. The bruise on her chin had turned purple. On 8/7/15 at 1420 hours, a telephone interview with the QIDP was conducted. The QIDP stated Client 1 was taken to see the Dentist of Oral Surgery. The Dentist concluded tooth #9 was gone and asked to see the tooth. The QIDP stated on the day of the incident, the entire area where Client 1 fell was searched and no tooth or anything was found. The QIDP continued saying tooth #8 was broken and would need to be removed to prevent it from getting infected or causing problems. The QIDP stated no pieces of a tooth were found. The QIDP stated an appointment for the removal of the tooth was made. The facility's P&P regarding use of the side rails was requested from the QIDP for review.The facility's undated P&P titled Using Bedrails, read in part: "2. Raise the bedrail immediately after positioning the client in the middle of the bed. 3. You may leave the bedrail down if you are standing beside the bed, facing the client, during dressing, changing, or repositioning the client. 4. Never walk away from the bed while the bedrail is down."The facility's failure to ensure their P&P for use of the side rails and changing a consumer in another consumer's bed were implemented resulted in Client 1 sliding off the bed, injured her mouth, and lost two of her teeth.The above violations, either jointly, separately, or any combination had a direct or immediate relation to the client's health, safety, or security. |
| 070000089 |
SKYLINE HEALTHCARE CENTER - SAN JOSE |
070008934 |
B |
23-Jan-12 |
EWHR11 |
7098 |
F323 - 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to prevent an accident on 2/19/11 when a volunteer pushed one of three sampled resident's (1) in a wheelchair without footrests to support her feet. Resident 1 became tired and requested wheelchair footrests but they were not provided. Instead the volunteer (V) instructed the resident to elevate her legs while V pushed the wheelchair. Resident 1's legs fell and the left leg became entangled in the wheelchair. Resident 1 sustained a painful sprained knee. Resident 1 was admitted to the facility with diagnoses including intestinal obstruction. The 1/1/11 Minimum Data Set (MDS) indicated the resident was able to ambulate using a walker and transfer with one person assistance to a wheelchair.During a telephone interview on 12/28/11 at 6:20 p.m. V stated on 2/19/11 Resident 1 told V she needed her footrests for the wheelchair, V stated the resident did not have footrests on her wheelchair but Resident 1 wanted to go back to her room. V stated she told Resident 1 that she would get wheelchair footrests some other day. V stated she instructed Resident 1 to lift her legs and place one leg over the other leg. V stated while she pushed Resident 1 to her room her legs uncrossed and fell. V stated licensed nurse A (LN A) was called right away. V stated two to three facility staff then helped the resident to her room.During an interview on 1/9/12 at 3:20 p.m., LN A stated on 2/9/2011 she was doing her medication count at the beginning of the afternoon shift when she was called to the area near the activity room. LN A stated Resident 1 was crying and holding her knee. Resident 1 sat a bit forward in her wheelchair and her left lower leg was bent under the wheelchair. LN A stated she asked V what happened and was told by V she pushed Resident 1 towards her room until Resident 1 stated, "Stop." LN A stated there were no footrests on the wheelchair. LN A stated she examined the resident and Resident 1 could not lift her left leg. LN A stated she asked staff to push Resident 1 back to her room after lifting and placing the resident's painful leg in a towel so that the legs would be off the floor and the wheelchair could be pushed. LN A stated the incident occurred while V pushed the resident from the dining room through the breezeway.During an interview with the activity director (AD) at 3:28 p.m. on 1/9/12, AD stated other than V, there were no witnesses to the actual incident when the resident's left leg became caught under the wheelchair. After the incident the wheelchair was noted not to have footrests. AD stated Resident 1 was initially pushed by V from the dining room to the breezeway.During an interview on 1/10/12 at 3:25 p.m., certified nurse assistant A (CNA A) stated she remembered helping Resident 1 to her bed last year. CNA A stated it took four staff to help the resident from the wheelchair to her bed. CNA A stated two staff members used a gait belt to help the resident transfer while two staff held the resident's legs. CNA A stated the resident was in "a lot of pain, lot of pain."During an interview on 12/29/11 at 2:25 p.m., restorative nurses assistant A (RNA A) stated prior to the incident Resident 1 used her feet to propel her wheelchair and at times the wheelchair footrests were kept under the resident's bed because the resident stated the footrests got in her way when she wanted to self-propel.During record review on 1/4/12 at 9:27 a.m., V's 9/23/10 employee file indicated she had no in-service documentation regarding resident positioning in a wheelchair, including the use of footrests on a wheelchair.During record review on 1/10/12 at 3:05 p.m., the facility's investigation indicated "On 2/19/11 around 3:45 p.m., [V] was asked by [Resident 1] to wheel her back to the nursing station." The document indicated Resident 1 did not have a footrest on her wheelchair. According to Resident 1 she told the activity aid she was waiting for the footrest from therapy. V told Resident 1 to lift up her feet so she could wheel the resident back to her nursing station. Resident 1 lifted her feet up and V proceeded to wheel the resident back to the nursing station. As they were going back to the nursing station V stated the resident's foot went back and V stopped wheeling the resident and came back to the dining room. An activity assistant (AA) called nursing so the nurse came to assess Resident 1. The February 2011 MAR indicated the resident was given one Vicodin on 2/19/11 when the incident occurred. The 2/25/11 ?Pain Evaluation? form indicated the resident had left leg and knee sprain pain.The MAR indicated from February 25, 2011 through March 31, 2011 Resident 1 was given either Tylenol or Vicodin almost daily for left leg pain.During an interview and record review on 1/10/12 at 1:30 p.m. the minimum data set coordinator (MDS) reviewed the January, February and March 2011 medication administration record (MAR) and stated staff gave the resident one pain medication in 2/2011 and it was for left leg pain on 2/19/11. After 2/25/11 and through 3/2011 the resident was given pain medications for left leg pain almost daily. MDS also reviewed the "Resident Functional Performance Records" dated January, February and March 2011 and stated Resident 1 had a decline in her ADL's including mobility and transfers after the resident returned to the facility on 2/25/11. During record review on 1/9/12 physician A (MD A) indicated in his 2/19/11 physician's progress notes "pushed in wheel chair with out foot support and lower left extremity tangled in wheel chair" causing severe pain in left knee and left leg "screaming in pain...x-ray ...femur fracture..." sent to acute hospital.According to MD A's progress note dated 2/26/11 when the resident returned from the acute care hospital she told the physician she asked for footrests for the wheelchair but it was unavailable. The volunteer rushed her resulting in an injury.The facility's undated policy, "Safe Patient Environment" indicated "accident prevention is everyone's responsibility. Most accidents can be prevented by being alert and anticipating hazards....Disability, reduces physical strength and unfamiliar surroundings increased the chance that accidents will happen. The long term patient is highly susceptible to accidents as muscle strength decreases, responses are slowed, balance is off...the factors make safety and accident prevention of vital importance to all persons involved in a long-term care facility." The facility failed to provide footrests on resident 1's wheelchair when Resident 1 asked for assistance to get to her room on 2/19/2011. The volunteer pushed Resident 1's wheelchair toward her room. Her legs went down and Resident 1 sustained a sprained knee. The above violation had a direct relationship to resident health, safety, or security of residents. |
| 070000061 |
SAN JOSE HEALTHCARE & WELLNESS CENTER |
070008994 |
B |
14-Feb-12 |
XSNY11 |
8324 |
F226 - 483.13(c) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC. POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to implement their policy and procedure for investigation of a resident to resident allegation of abuse between two of five sampled residents (1 and 2), failed to frequently monitor Resident 1's whereabouts according to the Resident Care Plan, and failed to report the allegation of abuse to the California Department of Public Health within 24 hours. These failures to investigate the allegation of resident to resident abuse between Resident 1, and Resident 2 and to monitor Resident 1 allowed a second incident to occur between Resident 1 and Resident 3 on 1/29/12. Resident 1 was admitted to the facility with diagnoses including after care for a fracture of the right leg. The Minimum Data Set (MDS, an assessment tool) dated 12/2/11 indicated Resident A was moderately impaired in cognitive skills for daily decision making. Resident 2 was admitted to the facility with diagnoses including Down's Syndrome. The admission assessment dated 1/22/12 indicated Resident B was nonverbal and needed extensive assistance with activities of daily living (ADLs). During an interview with Resident 4 on 1/31/12 at 1:15 p.m., she stated she was in the hallway in her wheelchair and she observed Resident 1 touching Resident 2 in between his legs. She stated she told Resident 1 to "stop" and told certified nurse assistant A (CNA) that Resident 1 was touching Resident 2 all over and in his groin area." He was licking his fingers and putting his hands in [Resident 2's] groin area." She stated CNA A did not say anything and just moved Resident 1. She stated she knew Resident 2 could not fight off Resident 1. She also stated Resident 3 and Resident 5 were in the hallway and witnessed the incident between Resident 1 and Resident 2. She stated there was another incident between Resident 1 and Resident 3. She stated Resident 3 was upset and crying because Resident 1 peeked in on her twice while she was getting ready for bed. During an interview with Resident 5 on 1/31/12 at 1:45 p.m., she stated she was sitting in her wheelchair in front of station 1 when she saw Resident 1 rubbing Resident 2's stomach and Resident 1 reached down and was playing with Resident 2's penis. She stated she looked at Resident 1 and shook her head side to side letting him know what he was doing was wrong. During an interview with Resident 3 on 1/31/12 at 2 p.m., she stated she was sitting in her wheelchair in the hallway in front of station 1. She stated Resident 1 was licking his fingers and grabbing Resident 2's private parts. She stated "the following day I told [Resident 2's] family member what had happened between [Resident 1 and Resident 2]". She also stated on 1/29/12 she was getting ready for bed and certified nurse assistant B (CNA B) was assisting her. She stated she was in a gown with the back side open and she was not wearing any underpants. She stated the curtain was drawn around her and all of a sudden Resident 1 opened the drapes and was staring at her back side. She stated CNA B removed him from the room and continued to assist her. She stated all of a sudden Resident 1 was there again, pulling the curtain and staring at her. During an interview with CNA A on 1/31/12 at 2:55 p.m., she stated that on 1/26/12, she was documenting her ADLs at station 1 when she heard Resident 4 yelling in a loud voice (like she was trying to get someone's attention) that Resident 1 was touching Resident 2 in his "private area". She stated she did not see what happened but her attention was called to Resident 4 because of her tone of voice. She stated she did not remember the exact words but Resident 4 used her hands in a circular motion indicating the area around her lower part of her body, indicating the private area on someone. She stated she saw Resident 1 putting his hand on Resident 2's hand. She stated she moved Resident 1 away from Resident 2 and had another CNA take Resident 2 to his room. She stated she then reported the incident to licensed nurse C (LN C). CNA A stated because she did not see anything she did not feel it was necessary to report. "It is hard to report something we did not see. It is one person's word against another person". CNA A stated she did not ask Resident 4 anymore questions about the incident or investigate further. During a telephone interview on 2/3/12 at 11 a.m. with LN C, she stated she was not aware of the allegation of abuse between Resident 1 and Resident 2. She stated she only found out about the incident when she was contacted by the director of nurses (DON) on 1/27/12 (the day after the incident). She stated if she had been aware of the incident she would have assessed the residents, made sure they were separated, would have reported the incident to the abuse coordinator, filled out the necessary paperwork and notified the California Department of Public Health. The clinical record for Resident 1 was reviewed on 1/31/12 and 2/3/12. The Activity Care Plan dated 12/19/11, indicated Resident 1 tends to touch others during activities and grabs belongings that are not his. Listed under approach: ask and remind to keep hands to self and encourage not to lick items and fingers.The Resident Care Plan dated 12/25/11 documented as a concern: sexually inappropriate behavior trying to touch female staff breast and buttocks. Listed under approaches: keep resident away from other residents and frequent monitor of resident's whereabouts. The Resident Care Plan dated 1/27/12 indicated Resident 1 alleged touching another male resident inappropriately in the groin. Resident has history of sexually inappropriate behavior trying to touch female staff breast and buttocks with psychiatric diagnoses per psychiatrist. Listed under approaches: frequent monitor resident's whereabouts. During an interview with the DON on 2/3/12 at 1:05 p.m., she stated if a resident lets the CNA know of an incident where one resident touched another resident inappropriately in the groin area, the CNA should separate the residents and let the nurse in charge know about the incident or allegation. She stated the CNA should have investigated further to determine where the resident was touched. When asked about the approaches listed on Resident 1's care plans, she stated the facility could not provide one to one nursing care and the staff should monitor where Resident 1 is located in the facility at all times. She stated staff should keep Resident 1 at arm's length from other residents. She also stated the incident was not reported to the California Department of Public Health until 1/30/12. The facility policy and procedure "Abuse Prevention Policy and Procedure" dated 7/14/10, indicated an employee who has observed or has knowledge of an incident that reasonably appears to be abuse, or has been told by an elder or dependent adult that he or she has experienced behavior constituting abuse shall report the incident to the appropriate authorities. The employee who has observed or has knowledge of an incident that reasonably appears to be abuse must report the incident immediately to his or her immediate supervisor who in turn reports the incident to the Administrator who is the facility's Abuse Prevention Coordinator. A physical assessment of the resident(s) involved will be completed by the charge nurse, with all findings and statements on the resident's record. All alleged, suspected, observed or reported abuse and injury of unknown source is reported to the California Department of Public Health, Licensing and Certification Division immediately or within 24 hours. The failure of the facility to investigate the allegation of abuse when it occurred on 1/26/12, prevented the facility from reporting the incident to the California Department of Public Health within 24 hours. The failure to keep Resident 1 at arm's length from other residents and to monitor Resident 1's whereabouts in the facility, allowed Resident 1 to enter Resident 3's room while she was preparing for bed. The above failure "had a direct or immediate relationship to the health, safety, or security of patients." |
| 070000089 |
SKYLINE HEALTHCARE CENTER - SAN JOSE |
070010263 |
B |
15-Nov-13 |
O1O611 |
7862 |
F323 - 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to adequately supervise and prevent one resident (1) from eloping (leaving the facility without permission or staff knowledge). After eloping, Resident 1 was found approximately 2.7 miles from the facility, 25 hours after he was discovered missing. On 11/4/13, the night Resident 1 eloped, the exterior temperature dropped to a low of 40 degrees. Resident 1 was able to leave unobserved from one of six unlocked exit doors which had no alarm system in place. Two of the exit doors were monitored on a continuing basis and staff was observed missing from the post for these two doors. The chair alarm system, in use by Resident 1 to alert staff when he stood up from his wheelchair, failed to function at the time of his elopement.Resident 1's clinical record reviewed on 11/5/13, indicated he was an insulin dependent diabetic, and also was to receive medications for high blood pressure and dementia. His 7/15/13 Minimum Data Set (MDS, an assessment tool) indicated he was confused at times and was only oriented to his name. He required one person assistance for transfer and had an unsteady gait. He used a wheelchair but was able to ambulate at times. He had previously eloped from the facility in April 2013. His 4/2013 Wandering/Elopement care plan had interventions to prevent his eloping in the future which included a WanderGuard (system of alarms on exit doors activated when residents leave the area or cross over a doorway threshold) bracelet and checking the alarm for functioning even though the facility had no WanderGuard system in place. Visual checks, encouragement to attend daily activities, and provide reassurance and redirection were also included interventions. On 11/5/13, a review of the facility's Brief Description of Incident form indicated the resident was last seen on 11/4/13 at 3:10 p.m. sitting in his wheelchair watching TV in his room. He was wearing a light blue shirt, light sweater, khaki pants, and shoes. At about 4 p.m., staff noted Resident 1's empty wheelchair next to the lobby elevator.During an interview on 11/5/13 at 1:30 p.m., the assistant director of nurses (ADON) stated a staff member noticed Resident 1's empty wheelchair by the lobby elevator. Resident 1 could walk, but usually used a wheelchair to wheel himself around the facility, so they initiated a search. She also stated the WanderGuard system, listed as an intervention on Resident 1's Wandering/Elopement care plan was never implemented since the system was not functioning. During an interview on the same day at 1:40 p.m., the receptionist (REC) stated he saw the empty wheelchair on 11/4/13. He verified the facility had been without a WanderGuard system for more than three years. He stated the system the facility had for residents at risk of elopement or wandering was a high risk fall binder at the receptionist's desk, containing the residents' names and pictures. The receptionist could then use this information to identify and stop residents before they left the facility. On 11/6/13 a review of the facility's 12/1/05 "Elopement" policy indicated, "Elopement Risk form will be completed for all patients upon admission, readmission, quarterly, and with significant changes. Patients at risk for elopement will have a wander guard band placed if applicable for facility, along with a completed Elopement Identification Form with attached photo. These forms will be placed in the Elopement Binder and maintained at the reception desk."A review of the high risk fall binder at the receptionist's desk had 15 residents' pictures and information pages. In the binder, the REC stated only four of these 15 residents were current residents with elopement risks. The other eleven residents had been discharged.During an interview on 11/5/13 at 2 p.m., licensed nurse B (LN B) stated Resident 1 could walk but was not very steady. She recalled Resident 1 eloped from the facility in 4/2013. There was no WanderGuard system in place, but Resident 1 had a chair alarm. She stated nobody heard the chair alarm activate at the time of his elopement.On 11/6/13 at 11:20 a.m., during a tour with the maintenance supervisor (MTS) the following were observed: There were six exit doors unlocked during the day. There was a main door and an elevator near it. The elevator led to the basement which opened to two hallways. One hallway was short, only about 10 - 15 feet and led to an unlocked door opening to the street. The other was a long hallway with an unlocked door opening to the parking garage. There were two doors at the back of the building (between Stations two and five) which led to a breezeway with an exit to the street/sidewalk. Only the main entrance and the nearby elevator were monitored and visible from the receptionist desk.During an observation on 11/5/13 at 4 p.m., after taking the elevator to the downstairs, the hallway was empty. All doors in the hallway were closed, except the activity department door. The hallway door was marked as being alarmed. The door was tested and no alarm sounded. During an interview at 2:05 p.m., the MTS stated the exit doors were only locked from 8 p.m. until about 6:30 a.m. Only the main door and elevator were monitored during the day. During an interview on 11/6/13 at 10:30 a.m., the social service assistant (SSA) stated after the elopement incident on 11/4/13, none of the staff interviewed heard the chair alarm. The SSA stated it was possible Resident 1 left through a downstairs door.During an observation on 11/6/13 at 12:25 p.m., of the reception desk in the lobby, where two exits were visible and monitored, no staff member was present for two to three minutes. During an interview on 11/6/13 at 2:05 p.m., the administrator (ADM) stated when the receptionist left for a few minutes and left the door and elevator unmonitored, this would be enough time for a resident to elope. The ADM also stated he was told the facility used to have a WanderGuard system. He stated he had looked into getting a system for the facility but only had a price quote at the present time.During an interview on11/6/13 at 8:35 a.m., Resident 1 was disoriented to time and place and unable to answer simple addition math problems. He had no information about where he had been during the missing 25 hours, or how he got there. During a telephone interview on 11/6/13 at 10:20 a.m., the medical director (MD) stated Resident 1's mental reasoning was getting worse. They were thinking of conservatorship (representative who makes healthcare decisions for someone not capable of doing so). The MD stated he was aware Resident 1 had eloped once before in 4/2013 and it might be time to place him in a facility with some security. During a telephone interview with a police detective (PD) on 11/8/13 at 8:45 a.m., he stated Resident 1was found by the emergency medical services crew approximately 2.7 miles from the facility and stated the location.An online review of the weather from the National Weather Service, for the time period Resident 1 eloped from the facility on 11/4/13 to 11/5/13, indicated the temperature dropped to a low of 40 degrees Fahrenheit.The facility failed to have adequate supervision. The facility failed to implement all the interventions on the resident's care plan or to revise them with new interventions, when the one written was unavailable. The facility also had a failure of an assistive device to prevent elopement when the chair alarm system in place for Resident 1 malfunctioned.The above violations had a direct or immediate relationship to the resident's health, safety or security. |
| 070000089 |
SKYLINE HEALTHCARE CENTER - SAN JOSE |
070010942 |
B |
28-Aug-14 |
J6DS11 |
5476 |
F323 - 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The Department determined the facility failed to provide the necessary supervision and services when they failed to implement interventions consistent with Resident 1's assessed needs which resulted in a left shoulder fracture and contusion. Resident 1, who was identified by the facility as requiring a two or more person transfer, was transferred by one person, resulting in a fracture to Resident 1's left shoulder. Resident 1 is 77 year old admitted to the facility with diagnoses including stroke and left sided hemiplegia (weakness on the left side of the body.) The facility assessment dated 5/7/14 indicated Resident 1 was totally dependent on staff for transfers and required two or more persons to transfer her. Resident 1 was not oriented and had memory problems.Resident 1's current "Kardex" (an abbreviated care plan used by certified nurse assistants as an aid to identify resident care needs) indicated Resident 1 was a total care for transfers and should be have "2 people transferring not 1."Review of Resident 1's Initial Nurse's Progress Notes dated 8/2/14 at 5:00 a.m., indicated Resident 1 complained of pain to her left shoulder and arm. Licensed vocational nurse E (LVN E) indicated she saw Resident 1's weak left side including the left arm and shoulder with "some swelling" and beginning bluish discolorations on the left upper breast and left upper inner arm. Resident 1 stated she had an afternoon shower on 8/1/14. LVN E notified the attending physician and Resident 1's responsible party.Review of Resident 1's "Weekly non-pressure Ulcer Records" (a skin assessment form) dated 8/3/14 indicated the following entries: a) discoloration extended "to the left breast" and towards the back of the arm pit with measurements of 14 centimeters (cm) X 27 cm b) greenish discolorations on the left clavicle (collar bone) with measurements of 4 cm X 4 cm c) left upper arm had multiple greenish discs with no measurements d) left upper back had greenish disc like discolorations with measurements of 5 cm X 2 cm e) right breast had a greenish disc discoloration with measurements of 8 cm X 22 cmReview of Resident 1's "Physician's Progress Notes" dated 8/2/14 at 7:30 a.m. indicated Resident 1's attending physician (MD D) received a telephone call at 6:00 a.m. regarding Resident 1's left shoulder bruising and pain and saw Resident 1's bruising with pain of her left shoulder. MD D ordered an X-ray of the shoulder. Review of Resident 1's X-ray results of the left shoulder dated 8/2/14 indicated "acute shoulder fracture." Review of Resident 1's general acute care hospital discharge instructions dated 8/2/14 indicated Resident 1 had a fractured shoulder and chest contusion. The instructions included notifying Resident 1 to use a shoulder immobilizer. Review of the Resident 1's "Physician's Progress Notes" dated 8/12/14 written by orthopedic (doctor specializing in bone disorders) physician G (MD G) indicated Resident 1 had a fractured left shoulder and was to wear the shoulder immobilizer.During an interview on 8/12/14 at 2:30 p.m., physical therapist H (PT H) stated rehabilitation director B (RD B) "told me [Resident 1] was always a total two person assist." During a telephone interview on 8/13/14 at 10:26 a.m., certified nurse assistant C (CNA C) stated he gave Resident 1 an afternoon shower on 8/1/14. He stated he transferred Resident 1 from her bed to the shower chair by himself.During a telephone interview on 8/13/14 at 10:38 a.m., physician D (MD D) stated he saw Resident 1 on 8/2/14 after staff reported the incident to him. MD D stated Resident 1 had bruises on her chest and arms. MD D stated he referred Resident 1 to an orthopedic physician (MD G) for treatment because Resident 1 had an acute left shoulder fracture.During a telephone interview on 8/13/14 at 2:03 p.m., LVN E stated she was responsible for providing Resident 1 care on 8/2/14 during the night shift. LVN E stated Resident 1 complained of pain at 1:00 a.m. and she gave Resident 1 some Tylenol, who fell asleep and stated at about 5:00 a.m., Resident 1 complained of pain again so LVN E assessed Resident 1's left shoulder at that time. LVN E stated the left shoulder area was swollen and tender. Resident 1's right breast, left under arm, left breast and shoulder were just "starting (to develop) discolorations (bruising) and turning red During an interview on 8/15/14 at 3:24 p.m., shift supervisor F (RN F) stated she assessed Resident 1 with LVN E the night Resident 1complained of pain. RN F stated Resident 1's left shoulder and breast area had some swelling and the beginnings of a bruise.Review of the facility's policy entitled "Resident Transfer: From Bed to Chair" dated 8/15/12 indicated a transfer with two person assist mandates the use of two persons for moving a resident safely between surfaces.The facility failed to provide adequate supervision during the transfer of Resident 1 according to her assessed needs. This failure resulted in Resident 1 being transferred by one employee, during which Resident 1's sustained a left shoulder fracture and chest contusion. The violation of this regulation had a direct relationship to the health, safety, or security of the resident. |
| 070000089 |
SKYLINE HEALTHCARE CENTER - SAN JOSE |
070011667 |
B |
01-Sep-15 |
9EJW11 |
4228 |
F309 - 483.25 Provide Care/Services for Highest Well-Being Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to provide the necessary care and services for Resident 4 who had a change in condition when a registered nurse (RN) failed to properly assess the resident who had severe symptoms of a heart attack and when she failed to call 911 to arrange for an emergency transport to the hospital. These failures led to a delay in treatment placing the resident at risk for health complications.Review of Resident 4's clinical record indicated he had diagnoses including a history of stroke, back surgery, and coronary artery disease (narrowing of the arteries and vessels that provide oxygen and nutrients to the heart). His Minimum Data Set (MDS, an assessment tool), dated 6/15/15, indicated he did not have problems with memory and in daily decision making skills. The Situation, Background, Assessment, Recommendation form (SBAR, a form used to facilitate prompt and appropriate communication), dated 6/24/15, indicated Resident 4's back pain went from 8/10 to 10/10 (highest level) thirty minutes after receiving Dilaudid (a potent narcotic pain medication). He stated he was "going to pass out." Resident 4 also was clammy and nauseated. He further stated he could not "take it anymore." Two ambulance companies were called and the wait time for non-urgent transport to the hospital was forty-five to fifty minutes and one and one-half hours respectively. A nurse's note, dated 6/24/15 at 2 a.m., indicated Resident 4 was still clammy and nauseated with 10/10 pain in his back radiating to his chest. At 2:20 a.m., Resident 4 was transferred to a hospital by ambulance.The hospital's History and Physical, dated 6/24/15, indicated Resident 4 presented with chest pain for three days, acutely worsening on the day of arrival and was experiencing shortness of breath, sweating, and nausea and vomiting. He was diagnosed with an acute heart attack and underwent two stent placements (procedure to open blocked heart arteries). During an interview on 7/29/15 at 5:35 p.m., registered nurse G (RN G) stated on 6/24/15, Resident 4 had severe back pain radiating to his neck and was insisting to go to the hospital's emergency room. RN G stated she did not call for an emergency transport because she thought his pain was from his back surgery. During an interview on 8/13/15 at 11 a.m., Resident 4 stated he had a recent back surgery and he hurt all of the time. At about 12 midnight on 6/24/15, he had the "worst pain in my life right in the front of my chest" and told his nurse, "I'm serious, you need to call 911." Resident 4 questioned why the ambulance took two hours to arrive. Resident 4 also stated until now "I really had bad panic attacks" and was "afraid" to have another panic attack. When the ambulance staff attended to him before he lost consciousness, Resident 4 stated he was told they were "nitroing" (giving nitroglycerin, a medication used to treat an inadequate flow of blood and oxygen to the heart) him and he was having a heart attack. During an interview on 8/13/15 at 3:30 p.m., the physician (MD) stated he was called regarding Resident 4's condition but did not remember what was said in detail. The MD stated if a resident was having pain and not doing well he should have been transported emergently to the hospital. During an interview on 8/13/15 at 4:30 p.m., the director of nurses (DON), who reviewed the record, stated the nurse should have called 911 for transport.According to http://www.heart.org, "Warning Signs of a Heart Attack," it indicated most heart attacks start slowly with mild pain or discomfort and listed signs of a heart attack including discomfort in the chest and back, cold sweat and nausea. Calling 911 was almost always the fastest way to get lifesaving treatment and it was best to call for rapid transport to the emergency room. The above violations of the regulation had direct or immediate relationship to the health, safety, or security of residents. |
| 070000089 |
SKYLINE HEALTHCARE CENTER - SAN JOSE |
070011668 |
B |
01-Sep-15 |
9EJW11 |
4941 |
F225 483.13(c)(1)(ii)-(iii), (c)(2) - (4) INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility failed to ensure Resident 2's allegation of verbal and physical abuse by a certified nurse assistant (CNA) was fully investigated, reported to the proper authorities and actions were taken to protect the residents during the investigation. Failure to report and investigate the alleged abuse prevented an analysis of the occurrence to determine the necessary changes to prevent abuse in the future and potentially allowed the abuse to continue.Resident 2's clinical record was reviewed and his Minimum Data Set (MDS, an assessment tool), dated 8/7/15, indicated he did not have problems with memory and daily decision making skills. A nurse's note, dated 7/27/15, described Resident 2 as alert and verbally responsive with periods of confusion. Review of a nurses note written by registered nurse B (RN B), dated 8/7/15 for the night shift, indicated a CNA reported Resident 2 was "verbally cursing staff, screaming and yelling" and alleged he was "firmly tapped" on his back. The same note indicated Resident 2 was reassured of his "safety."Review of a nurses note, dated 8/7/15 at 10:15 a.m., indicated Resident 2 made a complaint regarding a night shift CNA "firmly" tapping him on his back. There was no documentation indicating the roommate, CNA D and other potential witnesses were interviewed. During an interview on 8/12/15 at 3:30 p.m., Resident 2 stated several nights ago, CNAs C and D entered his room and pushed him on his side to perform incontinence care. One of the CNAs yelled at him and "slapped his hand." During the same interview, Resident 2's roommate stated he was awakened when the incident occurred. During an interview on 8/12/15 at 5 p.m., the administrator (ADM), who was the facility's abuse coordinator, stated he was informed of an allegation made by Resident 2 and instructed the staff to investigate the incident. The ADM stated CNA C, the staff person in question, was not suspended and was assigned to care for other residents on the same unit. The ADM stated the allegation of a resident being tapped on his back could be considered as an allegation of mistreatment.During an interview on 8/13/15 at 8 a.m., RN B, who reviewed the record, stated the incident was not reported to the ombudsman's office and the California Department of Public Health (CDPH) because Resident 2 had behavior problems and she considered the incident to be a grievance. During an interview on 8/13/15 at 8:40 a.m., CNA C stated Resident 2 swore at her and told her to "get out." When CNA C was at the door, she heard Resident 2 stating, "She hit me two times." During an interview on 8/13/15 at 8:50 a.m., CNA D, who confirmed she also attended to Resident 2 at the same time with CNA C, heard Resident 2 "screaming" a false statement of, "She hit me." During an interview on 8/13/15 at 5:15 p.m., the director of nurses (DON) stated the allegation was not reported to the CDPH and the ombudsman because, "We put it in a grievance because of the investigation." The facility's 10/2004 policy, "Abuse & Neglect Prohibition", indicated the facility was to conduct an investigation of any alleged abuse in accordance with state law and would report such allegations to the state as per state regulations. The same policy indicated the facility would protect the residents from harm during the investigation. The violations of this regulation had a direct or immediate relationship to the health, safety or security of residents. |
| 070001060 |
SHINRAI-FLINTDALE |
070011682 |
A |
25-Nov-15 |
9OZZ11 |
11023 |
Welfare and Institutions Code 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following:(h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse or neglect. The facility failed to ensure Client 1's right to be free from harm. On 7/20/15 at around 10 a.m., direct support staff A (DSP A) was instructed to pick up Client 1 from the day program (DP, a community based program that provides care to persons in need of personal services supervision or assistance essential for sustaining the activity of daily living). On the way from the DP to the facility, DSP A suddenly stopped the van when a car ahead of them made a sudden stop. Client 1 fell from his wheelchair to the floor of the van onto his knees, then his left shoulder and head. DSP A pulled over to the side of the road and after a visual check, assisted Client 1 back to his wheelchair with the help of somebody at a nearby store. DSP A then drove to the facility where Client 1 was sent to the hospital for an evaluation. An X-ray dated 7/20/15 revealed a fracture of the distal left femur.Client 1 had diagnoses including muscular dystrophy (a group of muscle diseases that weaken the musculoskeletal system and impede movement), osteoporosis (a disease where decreased bone strength increases the risk of a broken bone) and mild intellectual developmental disabilities (a significant limitation in both intellectual functioning and in adaptive behavior which covers many everyday social and practical skills). The Comprehensive Functional Assessment (CFA, an assessment tool), dated 2/27/15, indicated Client 1 was nonambulatory but able to use his electric wheelchair independently with his right hand. He was able to express his needs and wants. The CFA also indicated Client 1 enjoyed community outings and preferred his activities in the community rather than at home. There was no documented assessment of Client 1's safety awareness. The lncident Report, dated 7/21/15, indicated Client 1 fell off his wheelchair on the way back to the facility. The qualified intellectual disabilities professional/administrator (QIDP/ADM) talked to Client 1 at 11:25 a.m. According to the client, his seatbelt was not buckled on. After the QIDP/ADM visually assessed Client 1 in the facility, he was taken to a hospital for an evaluation. The emergency department report dated 7/20/15 indicated Client 1 fell out of the wheelchair during transport and an X-ray of the left knee was done, with the result of a minimally displaced fracture of the distal femoral diaphysis and lateral supracondylar femur with large lipohemarthrosis (broken thighbone). A leg cast (a shell encasing a limb to stabilize and hold a broken bone in place) was applied for immobilization and he was given oxycodone-acetaminophen (Percocet, a pain medication). As per the Incident Investigation Report dated 7/21/15, at 3 a.m. the staff returned to the facility with the client who had a cast.During a telephone interview with DSP A (driver of the van) on 7/28/15 at 2 p.m., he stated he picked up Client 1 on 7/20/15. He stated he secured the wheelchair with the four safety belts on the floor of the van but did not secure the safety seatbelt connected to the ceiling of the van because it was not working. DSP A stated he did not know how long the van's seatbelt was broken because he relieved a regular van driver who was on vacation, and he did not check to see if Client 1's seatbelt or chest strap was secured after loading him inside the van. DSP A stated after the incident Client 1 complained of pain in his left leg. However, DSP A said he did not see anything, and he asked someone from a nearby store to assist him to get Client 1 back in his wheelchair. DSP A then drove to the facility. DSP A stated he had worked at the facility for six months and the inservices on van safety were provided after the incident occurred. During an interview with the QIDP/ADM on 7/28/15 at 2:45 p.m., she stated she observed Client 1's body was shaking upon his arrival to the facility. He also had complaints of pain in his shoulder and left knee. The QIDP/ADM stated a small scratch on his left knee was observed but there was no skin discoloration. Client 1 was assessed visually and given a pain medication (Tylenol). The QIDP/ADM stated Client 1 was able to eat his lunch before she took him to a hospital for an evaluation. Further interview with the QIDP/ADM indicated DSP A was not evaluated after his three month probation period. He was designated as a substitute driver but had not signed the "Paratransit Driver Form" indicating he had training on the safe operation of the facility's van. She stated DSP A only had verbal instructions from the regular driver (RD) before the RD went on vacation. She also acknowledged DSP A should have called 911 to request paramedics arrive to the scene to assist with Client 1. During an observation and concurrent interviews on 7/29/15 at 9:15 a.m. with DSP B and C, the safety seatbelts connected to the ceiling were tightly tied up. DSP B (the new substitute driver), stated he did not use the van's seatbelt during the morning because he was told by DSP A it was broken. He also stated he had been driving the van for a week. DSP C, who had been working in the facility for three years and assisting with loading a client, stated he noticed the safety belts in the ceiling had been tied for some time and he had mentioned this to the regular driver who was currently on vacation. During an interview with DSP B on the same day at 11:05 a.m., he stated he looked in the van and found the extension belts. Nobody knew they were there. He also stated he knew how to use them from his own experience and had no formal van training until 7/29/15. During an observation and interview with Client 1 on 7/29/15 at 12:50 p.m., he was in his bed with a long leg cast on his left leg. He was awake and hesitant during the interview. Client 1 was able to move his right arm slowly and spontaneously but moved his left arm only when asked. He stated he was not wearing his seatbelt and his chest strap during the accident. He stated DSP A only fastened his wheelchair to the floor belt. He said his seatbelt was removed when he went to the bathroom in the DP before leaving. Client 1 stated he could not buckle his seatbelt because his upper extremities were weak. He stated DSP A had to suddenly stop for a red light during the trip when he fell out of his wheelchair inside the van, and his left knee and shoulder hurt after the fall.During a review on 7/28/15 of Client 1's clinical record and an interview at 3:40 p.m. with the registered nurse consultant (RNC), there were no documented care plans for a fall and the long leg cast. RNC acknowledged she had not initiated the plans of care for Client 1. Further record review indicated a physical therapist recommendation, dated 9/21/2012, indicated "1 pair lateral trunk supports to insure proper trunk alignment and functional positioning of upper body and to prevent leaning to either side. Patient has no trunk control... Padded seat belt to maintain proper positioning of pelvis, preventing sliding onto coccyx and also required during vehicular transport." During an observation of Client 1's wheelchair on 7/29/15, there was a slight contour on the back of the wheelchair. There was no other device attached to the wheelchair except a chest strap attached to both sides.Client 1's physician orders were reviewed for May through July 2015. There was no written physician order for a chest strap for Client 1's wheelchair. During an interview on 7/29/15 at 3:15 p.m. with the executive director (ED), he stated a lateral trunk support was a piece added to each side of the wheelchair for trunk support. A chest belt was different and required a physician order because it could restrain a client's movement. A chest belt would also be discussed during the human rights meeting. A concurrent review of the human rights binder did not indicate Client 1 had a chest strap ordered. During an interview with the QIDP/ADM on 8/7/15 at 2 p.m., she stated the wheelchair was delivered in 2013 with the chest strap. She stated she was not sure whether the wheelchair had "trunk support." She confirmed nothing was added to the wheelchair backrest except an attached chest strap. During an interview with a physical therapist (PT) on 8/7/15 at 2:10 p.m., she stated the trunk support was part of the wheelchair while a chest strap was for added safety. She said she recommended the device to the physician, and did not verify a chest strap was included in her recommendation. She stated the recommendations should be ordered by the physician. A record review on 7/29/15 of the facility's policy indicated the following: 1) "Personnel Job Description-Paratransit Driver" indicated the staff should focus on the safe operation of the vehicle that transports clients who have physical and intellectual challenges. The staff should have training to check the seatbelts of the van and the tie downs to ensure all are in good working condition. 2) ''Transportation Policy" indicated the driver must check the seat belts and ensure all of the passengers have seat belts that are in working condition. 3) "Emergency Procedures for Fall-Transportation Plan - off-site" indicated not to attempt to move or assist the client. If any doubts exist about an injury, the staff should call 911. 4) "Three Month Probationary Period'' indicated all employees would be on a probationary status for a period of three months and at the end of the three months, the employee would be evaluated to determine if the employee was suitable for employment or an additional three months of training.5) "Types of Orders" indicated any medication, including over the counter (OTC) medications that are given to a client must have a doctor's order. The types of doctor's orders included things such as side rails at night, leg elevation, etc. The facility failed to ensure the client's right to be free from harm. The facility failed to implement general policies and procedures in the facility including the necessary and adequate training of the staff to ensure Client 1's safety. Client 1 sustained a broken left thigh bone from the incident. The violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result for Client 1. |
| 070000061 |
SAN JOSE HEALTHCARE & WELLNESS CENTER |
070011840 |
B |
13-Nov-15 |
L4TC11 |
4849 |
F323 - 483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide adequate supervision and a well-functioning WanderGuard (a tracking device designed to prevent a person at risk from leaving the facility unless they are accompanied) when Resident 1 left the facility in a wheelchair by herself and went to the facility's back parking lot. This incident resulted in Resident 1 being hit by a car sustaining abrasions and skin tears to the right temporal area, right elbow and right hand. Resident 1 had a diagnosis of dementia (a progressive condition characterized by memory impairment/memory loss). The Minimum Data Set (MDS, an assessment tool) dated 9/6/15 indicated Resident 1 had long and short term memory problems and impaired decision making. The same MDS indicated Resident 1 required one person assistance with her activities of daily living (ADLs) including wheelchair mobility. During an interview on 10/19/15 at 11:00 a.m., the director of nursing (DON) stated Resident 1 needed assistance with her ADLs due to her intermittent confusion. She was also assessed for risk of elopement and wandering. An order for a WanderGuard was obtained for safety, and nursing staff were to check for placement and function every shift. During an observation on 10/19/15 at 11:10 a.m., Resident 1's WanderGuard and one other WanderGuard were tested and were functioning well. During an interview on 10/19/15 at 11:20 a.m., DON stated her theory was somebody turned off and reset the door alarm and did not notify the certified nursing assistant (CNA) and/or the licensed nurse (LN). Review of Resident 1's care plan for wandering/elopement on 10/19/15 dated 4/29/15 indicated Resident 1 loved to go to the back parking lot to enjoy fresh air which was not safe secondary to cognitive deficit.Review of the facility's incident report log on 10/19/15 indicated on 10/7/15 at 6:00 p.m., Resident 1 was found on the ground in the back parking lot. Resident 1 sustained an abrasion on right temporal area, right elbow and skin tear to the right hand. During an interview on 10/19/15 at 10:00 a.m., DON stated Resident 1 told her while she was waiting for her friend in the back parking lot, a car hit her while backing out from the parking space and she fell on the ground. The driver of the car helped her, by putting her back in her wheelchair, then drove away.During an interview on 10/19/15 at 1:30 p.m., Resident 1 stated she was waiting for her friend in the back parking lot and wheeled herself towards the brick wall at one end of the parking lot. When her friend did not show up, she decided to turn around to return into the facility. She heard the driver starting the car, and she yelled, "Do not back up the car, I'm behind you." Resident 1 stated she yelled several times, but the car continued moving towards her and hit her. She was thrown out of her wheelchair to the street curb. Resident 1 stated she was shocked and did not know what happened. The driver of the car helped her, put her back in her wheelchair and drove away. During the interview, Resident 1 was observed to be uneasy and her eyes became teary. She stated, "I'm sorry, I could not help but cry every time I was reminded of the incident. I am so scared." During an observation on 10/19/15 at 2:10 p.m., the brick wall at one end of the parking lot where Resident 1 waited for her friend was approximately two to three steps away from a busy street.During an interview on 10/21/15 at 11:10 a.m., the administrator (ADM) and DON both agreed Resident 1's statement of the incident was consistent.During an interview on 10/21/15 at 1:00 p.m., Resident 1's primary physician (PP) stated Resident 1 was cognitively impaired and required a lot of supervision at all times. PP also stated Resident 1 might function well inside her room but needed to be with somebody especially going outside the facility.During an interview on 10/27/15 at 8:30 a.m., CNA A stated she saw Resident 1 in the middle of the parking lot. CNA A approached Resident 1 so she could bring Resident 1 back inside the facility. CNA A stated she did not know about the incident but a family member told her that Resident 1 was hit by a car. Resident 1 confirmed the incident. CNA A reported the incident to the charge nurse. Review of the police officer investigative summary report on 10/27/15 dated 10/7/15 indicated party #1 (driver of the car) was backing out of a parking stall. Party #2 (Resident 1) was in her wheelchair behind party #1. Party #1 collided with party #2.These violations had direct or immediate relationship to the health, safety or security of the resident. |
| 070000089 |
SKYLINE HEALTHCARE CENTER - SAN JOSE |
070011928 |
B |
31-Dec-15 |
K1BR11 |
7982 |
F157- 483.10(b)(11) Notification of Changes A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in ?483.12(a). The facility must also promptly notify the resident and, if known, the 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. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member. The Department determined the facility failed to ensure the staff notified a physician in a timely manner of changes in the condition of Resident 1 when his X-ray (a photographic or digital image of the internal composition of a part of the body) result showed a hip fracture and his laboratory report showed a critically low blood test result which could have had the potential to cause a delay in treatment and a health decline.1. A review of Resident 1's clinical record indicated he had a recent unwitnessed fall resulting in a hip fracture, hip surgery, and small subdural hematoma (collection of blood between the brain and the skull).The post-fall Situation Background Assessment Recommendation (SBAR, a communication tool used to facilitate prompt and appropriate communication during a resident change of condition), dated 11/5/15, at 3 p.m., indicated Resident 1 was found sitting by his bed, with no sign of injury, no bruising, and no complaint of pain. The nurses note, dated 11/5/15, at 11:45 p.m., indicated Resident 1 complained of pain in his right thigh and hip with a pain level of three on a scale of one to ten (ten as the highest level of pain) when the leg was moved. The note indicated the primary care physician (PCP) was notified of Resident 1's pain and ordered an X-ray of the right thigh and hip to be completed in the morning.The X-ray report, dated 11/06/15, at 9:18 a.m. and faxed to the facility at 2:16 p.m., the same day, indicated Resident 1 had an acute fracture of the upper thigh bone (a break in the bone caused by a one-time force). An SBAR, dated the same day, at 4 p.m., indicated the licensed nurse was unable to reach the PCP, spoke to the PCP's secretary, and faxed the 11/6/15 X-ray result to the PCP's office at 4:15 p.m.The SBAR, dated 11/7/15, at 7:10 a.m., indicated Registered Nurse B (RN B) obtained an order to send Resident 1 to an acute care hospital. RN A stated the nurses were unable to reach the PCP on 11/6/15. RN B stated she would have called the medical director and the director of nurses (DON) and transported Resident 1 to the hospital at the time they received the report of the fracture.During an interview with the DON on 11/18/15, at 11 a.m., she stated when the nurses were unable to reach the PCP, the nurse in charge should have notified her and called the medical director to obtain an order to transfer Resident 1 to the acute hospital. She stated the facility does not have a policy to call the medical director when they were unable to reach a physician.During an interview with the PCP on 11/18/15 at 1 p.m., he stated the nurses should have sent Resident 1 to the acute hospital when the resident's X-ray showed he had a fracture. He stated sending a resident with a fracture to the hospital does not require his authorization. During an interview RN A on 11/25/15, at 3 p.m., she stated on the evening shift of 11/6/15, she was aware of Resident 1's fracture but was unable to reach the PCP to obtain the order to transfer the resident to the acute hospital. She stated she did not know she was supposed to call the medical director if she was unable to reach the PCP. 2. A laboratory report dated 11/18/15, indicated RN C was informed by a telephone call from the laboratory staff at 8:18 a.m. of Resident 1's critical level (life-threatening unless something was done promptly) hemoglobin level (Hgl., red blood cells required to deliver oxygen to the body, normal values: 13.7-17.5 grams per deciliter [g/dl, a unit of measurement]) of 6.8 g/dl. The report indicated RN C read-back (mandated practice of critical values read-back to the laboratory staff to verify the test results) the Hgl level at 8:18 a.m. Review of the SBAR, dated 11/18/15, indicated the PCP was notified of the Hgl level of 6.8 g/dl at 6:10 p.m. A physician order was then obtained to transfer Resident 1 to the acute hospital. During an interview with RN D on 11/19/15, at 10:15 a.m., she stated she first saw the laboratory report with the critical Hgl level placed on her desk at 2 p.m. on 11/18/15. RN D stated she faxed the report to the PCP after she placed a call to the PCP's office staff.During an interview with RN C on 11/19/15, at 1 p.m., she stated she received telephone notification of Resident 1's critical laboratory result but did not call the physician and did not assess Resident 1. She stated she was sure Resident 1's nonlicensed caregiver would let her know if there was a problem. RN C stated she waited most of the day to receive the faxed results. During an interview with the DON and the corporate nurse consultant on 11/19/15, at 2 p.m., the DON stated critical laboratory values should be called to the physician immediately. The DON stated the nurse should have assessed Resident 1 for negative effects of an abnormal Hgl level, should have notified the DON, and should have notified the medical director if she was unable to reach the PCP. She stated they were unable to find a policy for reporting abnormal test results to the physician but the situation should be treated as an unusual occurrence.During an interview with the PCP on 11/20/15, at 1:45 p.m., he stated the nurse should notify him immediately of a critical laboratory result, and if unable to reach him, the medical director should be notified in his place. The PCP stated he checked his records of 11/18/15 and was unable to find notification until 3:56 p.m. of the Hgl of 6.8 g/dl for Resident 1. The PCP stated if someone had an Hgl of 6.8 g/dl, it could be life threatening or lead to a heart attack.Review of the facility's 10/2003 "Registered Nurse" job description indicated nurses should communicate all changes in condition and abnormal diagnostic test results to the physician. Review of the facility's 2008 policy, "Change in Resident Condition", indicated the licensed nurse should notify the physician about a significant change of condition, a need for a new form of treatment or a decision to transfer the resident from the facility. The Stanford Hospital: Critical/Panic Values (http://www.stanfordlab.com/pages/panicvalues.htm) indicated a hemoglobin less than or equal to 7.0 g/dl on the list of critical values was defined as values outside of the normal range to a degree requiring immediate action on the part of the physician and may constitute an immediate health risk to the individual. The facility failed to ensure the staff notified a physician in a timely manner of changes in the condition of Resident 1's hip fracture and his critically low blood test result. The violation of the regulation had a direct or immediate relationship to the health, safety, and security of the resident. |
| 070001025 |
SHINRAI-GRIDLEY |
070012020 |
B |
09-Mar-16 |
YXYL11 |
4126 |
Welfare and Institutions Code 4502(b) Rights of Persons with Developmental Disabilities 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: (b) A right to dignity, privacy, and humane care. To the maximum extent possible, treatment, services, and supports shall be provided in natural community settings. The facility failed to ensure Client 3's right to dignity when the staff did not implement facility policy regarding clients' rights by, over the client's objections, continuously placing a bib on the client during breakfast and dinner to protect the client's clothes from getting dirty. Client 3's clinical record was reviewed. He was admitted in 6/2004 with diagnoses including status post head trauma, a craniotomy (an operation to open the skull in order to access the brain for surgical repair), and severe intellectual disability. Client 3's comprehensive functional assessment (CFA), dated 8/10/15, indicated he was able to express his needs. He was very social, liked to interact with his peers and the staff, and had good comprehension and social conversation skills. Client 3 spoke slowly in a low tone of voice. He was not able to walk but he could stand with assistance for short periods of time.During an observation on 1/26/16, at 9 a.m., Client 3, who was in a wheelchair, was assisted by direct care staff A (DCS A) to the dining area. He was wearing a helmet, was alert, and was able to talk in short sentences. At 9:20 a.m., DCS B served him breakfast and fastened a bib around his neck. Client 3 slowly scooped the food with a spoon and fed himself. While eating, he slowly pulled the bib down a couple of times. DCS B then told him not to remove his bib because his clothes would get dirty. Client 3 finished his food with the bib on. During a dinner observation on 1/20/16, at 5:35 p.m., Client 3 was served dinner. He was wearing a bib. While eating, he removed his bib but DCS C fastened the bib back around his neck and told him not to remove his bib. Client 3 finished his meal with his bib on.During an observation and interview on 1/27/16, at 5:30 p.m., Client 3 was served his meal. Again, he was wearing a bib. In a concurrent interview, Client 3 shook his head and indicated he did not like to wear a bib. DCS C unfastened the bib from his neck and placed it on top of his shirt. Client 3 continued to eat slowly and finished his food with the bib on top of his shirt. During another dinner observation and interview on 1/29/16, at 5:35 p.m., Client 3 was eating his meal. A bib was placed next to him, on top of his lap tray. In the presence of the QIDP/ADM, Client 3 was asked if he liked to wear a bib and he responded by saying, "No, I am not a child." He did not wear the bib. On 2/2/16, at 7:50 a.m., during breakfast, Client 3 was observed eating with a bib placed on top of his shirt. While he ate, the bib fell on his food. During a concurrent interview, Client 3 expressed to DCS C and licensed vocational nurse A (LVN A) his dislike of wearing a bib. The bib was removed. During an interview on 2/2/16, at 8:45 a.m., the QIDP/ADM stated a bib should not be placed when the client refused to wear it. Review of the facility's undated policy, "Clients Rights," indicated the clients had the right to dignity, privacy, and humane care and the right to make choices in their own lives.The facility failed implement the policy for client rights for Client 3 when the staff insisted Client 3 wear a bib even after he refused. These violations had a direct or immediate relationship to the health, safety, or security of the clients. |
| 630012069 |
SHINRAI-WHITE |
070012173 |
B |
22-Apr-16 |
N72C11 |
7940 |
Welfare and Institutions Code 4502(d) Rights of Persons with developmental disabilities 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 nursing services necessary to meet the needs of a medically and highly compromised client (1). The direct care staff (DCS) and the registered nurse (RN) failed to assess and provide prompt medical care and treatment when Client 1 had signs and symptoms of pain after a fall incident. On 3/29/16 Client 1's record was reviewed. Client 1's comprehensive functional assessment dated 12/21/15 indicated she had the following diagnoses: dementia, autism, and severe intellectual disability. She was non-verbal and communicated her needs through facial gestures and grimaces. A physician's order dated 2/1/16 indicated to give the client Tylenol 500 milligrams one tablet every four hours as needed for pain. The care plan dated 12/4/09 indicated "potential for discomfort/pain" the action and approaches were as follows: assess for any signs/symptoms of pain such as grimacing, guarding. Use pain assessment tool, give "prn" Tylenol. Evaluate effectiveness of pain, notify physician if no relief noted.The nursing progress notes dated 3/19/16 indicated at around 7:15 p.m., the RN received a call from facility staff regarding Client 1's fall incident. DCS A and B lifted up Client 1 from the floor to the couch. Upon arrival to the facility the RN took Client 1's vital signs. During an assessment the RN noted Client 1's back and hip area were tender when touched. The RN could not further assess the client's torso (shoulder down to the hip) especially the back area since the client was uncooperative and showed facial grimacing when her back and hips were touched. Client 1 refused to stand. There was no evidence the RN assessed Client 1 for pain.The acute care hospital history and physical notes dated 3/20/16 indicated Client 1 was diagnosed with status post fall and fracture of the left pelvis (hip).During an observation on 3/28/16 at 9:30 a.m., Client 1 sat in her wheelchair and watched television in the living room. She was awake and alert. She responded through facial expressions and could answer questions with "yes" and "no". During an interview on 3/28/16 at 10:00 a.m., the RN stated on 3/19/16 around 7:00 p.m., she received a telephone call from the facility staff who informed her Client 1 fell in the living room while ambulating. The RN stated she instructed the staff to take the client's vital signs (measurement of the body's basic function which includes body temperature, the pulse rate, respiratory rate, and blood pressure).The RN stated at 8:00 p.m., upon arrival in the facility she immediately assessed Client 1 who sat on the couch and the RN found the client's upper left hip was tender to the touch. The client was also manifesting "muscle guarding" (a protective response in the muscle that results from pain or fear of movement) and facial grimacing. The RN stated she attempted to assist the client to stand and checked the client's upper and lower extremities but the client refused to move her upper and lower extremities. The RN stated "maybe because she was in pain".When asked, the RN stated she did not assess the pain level although she noticed Client 1's facial grimacing and muscle guarding. She stated at that time she was in the process of calling the physician, the client's guardian, and the ambulance and she forgot about managing the client's pain. She also stated Client 1 had an order for pain medication as needed but was not given pain medication when the client manifested signs and symptoms of pain from 7:00 p.m., through 9:30 p.m. The RN stated at 9:30 p.m., Client 1 was sent to the hospital via ambulance. The RN stated Client 1 should have been assessed for her pain level and given pain medication. During an interview on 3/29/16 at 11:00 a.m., DCS A stated on 3/19/16 at around 7:00 p.m., Client 1 fell on the living room floor. DCS A stated she and another staff lifted Client 1 from the floor to the couch by pulling up while holding on to Client 1's pants. DCS A stated while in the process of lifting, Client 1 screamed, "Ouch"! DCS A stated the client was "probably" in pain during transfer. DCS A stated she did not check Client 1 further for signs of pain, i.e., facial grimacing. DCS A stated she did not offer pain medication but instead she waited for the registered nurse to arrive.During another interview on 3/28/16 at 4:00 p.m., DCS B stated while preparing other clients' medications in the medication room he heard a heavy dull sound from the living room and one of the other clients yelled that somebody fell. DCS B stated he ran to the living room and saw Client 1 lying on the floor. He helped DCS A to transfer Client 1 from the floor to the couch by pulling the client's pants and lifting under her armpits. DCS B stated while lifting, Client 1 screamed "ohhh", made faces and resisting movement, i.e., rigidity. DCS B also stated Client 1 was moaning and groaning intermittently while resting on the couch. DCS B stated the RN was informed of the incident after the client was already transferred to the couch. DCS B stated they waited for the RN to assess the client. He further stated Client 1 was not given any pain medication when she displayed symptoms of facial grimaces and screaming of pain and intermittent moaning for two hours. DCS A and B both stated they did not further assess the client's pain level when she showed signs and symptoms of facial grimacing, moaning, and resisting movement.The facility's undated policy and procedure, "Managing Fall and Face Pain Rating Scale" indicated: Assess the client's strength and motion. Note if the client complained of any odd sensations or limited movement. Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. The "Wong Baker Faces Pain Rating Scale was as follows: Face 0- very happy because he does not hurt at all. Face 1- hurts just a little bit. Face 2- hurts a little more. Face 3- hurts even more. Face 4- hurts a whole lot. Face 5- hurts as much as you can imagine. Although you do not have to be crying to feel this bad. Point to each face using words to describe the pain intensity. Ask the e client to choose face that best describes own pain and record appropriate number. Pain discomfort in any area: Monitor the particular area of pain and discomfort. Take vital signs and refer to the Universal Pain Tool Management to attempt to measure amount and intensity of pain (pain scale). If pain medications are ordered by the physician, administer and check results in one hour. If pain continues or is more severe call the RN. The facility failed to asses and provide prompt medical care and treatment when Client 1 presented signs and symptoms of pain after a fall incident. The facility staff failed to assess and evaluate Client 1's level of pain when she screamed and intermittently moaned for over two hours, displayed facial grimaces, and resisted movement after she fell on the floor. The facility staff failed to administer pain medication as part of their protocol to manage Client 1's pain symptoms.The above violation had a direct or immediate relationship to the health, safety, or security of the client. |
| 070000086 |
SAN TOMAS CONVALESCENT HOSPITAL |
070012196 |
B |
22-Apr-16 |
VCKZ11 |
2199 |
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. Resident 17's clinical record was reviewed. Her 3/5/16 nurses notes indicated a skin discoloration on her right lower eyelid. The resident did not know what happened and there was no further assessment and investigation of the potential cause of the bruise. Her skin discoloration care plan, dated 3/5/16, indicated she had a bruise measuring 2.5 centimeters (cm, unit of measurement) by 1.5 cm.During the initial tour on 4/6/16, at 7:45 a.m., with licensed vocational nurse D (LVN D), Resident 17 was observed to have a purplish discoloration on her lower eyelid. LVN D stated she did not know how the injury occurred. During an interview on 4/7/16, at 3:05 p.m., certified nurse assistant J (CNA J) stated a week after the injury, Resident 17 told her another resident hit her in the eye. CNA J stated she reported this to the nurse but she cannot recall the name of the nurse or the date she spoke to her.During an interview on 4/8/16, at 11 a.m., the director of nurses (DON) stated she noticed the discoloration on Resident 17's right eye several weeks ago. She stated she asked the resident and several staff members what caused the injury but no one advised her another resident hit Resident 17. She stated she would have done an investigation if the incident had been reported to her. The DON confirmed she did not have any documentation of an investigation and she did not call local law enforcement, the ombudsman, and the California Department of Public Health (CDPH). The facility's abuse policy did not indicate how to investigate and report an injury of unknown origin. However the inservice policy, "Recognizing and Reporting Elder Abuse", indicated a possible physical abuse indicator included bruises and skin damage. For suspected abuse, any concerned citizen and staff members who provided care and services were mandated reporters. The above violation has a direct or immediate relationship to the health, safety, or security of the resident. |
| 070000086 |
SAN TOMAS CONVALESCENT HOSPITAL |
070012205 |
B |
22-Apr-16 |
VCKZ11 |
2418 |
Class B Citation - ABUSE 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. Resident 12's clinical record was reviewed. Her Minimum Data Set (MDS, an assessment tool), dated 2/16/16, indicated she had impaired cognition and needed assistance with her activities of daily living (ADLs, included bed mobility, transfer, dressing, eating, hygiene, and bathing). Resident 12's Interdisciplinary Team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for a resident) Notes, dated 3/31/16, indicated the social worker from an outside agency who managed the resident's care, reported the resident was hit on her bottom and her hand by an unidentified man. The social worker also reported the incident to Adult Protective Services (APS, State mandated services provided to insure the safety and well-being of elders and adults in danger of being mistreated or neglected and unable to take care of themselves), the ombudsman, and the police department. During an observation and interview with Resident 12 on 4/7/16, at 4:30 p.m., she was sitting in her wheelchair and stated she was hit by a man but she forgot his name. During an interview with social service designee A (SSD A) on 4/7/16, at 4:15 p.m., she stated Resident 12 was hit on her bottom and her hand by an unidentified man. She also stated she sent a report to the ombudsman but did not report the incident to the California Department of Public Health (CDPH). During an interview with the director of nurses (DON) on 4/7/16, at 10:35 a.m., she stated she was aware Resident 12 was hit on her bottom and her hand by an unidentified man and the incident was not reported to the CDPH. She also stated there was no need to report the incident to the CDPH since the facility did the investigation. Review of the facility's undated policy, "Abuse Prevention", indicated mandated reporters were to make a report to CDPH by telephone immediately or as soon as practically possible but not to exceed 24 hours after an incident was reported and to the local ombudsman or to the local law enforcement agency. The above violation has a direct or immediate relationship to the health, safety, or security of the resident. |
| 630012069 |
SHINRAI-WHITE |
070012212 |
B |
22-Apr-16 |
N72C11 |
6104 |
Title 22 76916(a)(d) Policies and Procedures (a) Each facility shall establish and implement the following policies and procedures: (d) All policies and procedures required by Section 76916 shall be in writing, made available upon request to clients or their agents, employees and the public, and shall be carried out as written. Policies and procedures shall be reviewed at least annually, and revised as needed. The facility failed to follow their policy and procedure for Client 1 when two direct care staff members (DCS) moved and transferred Client 1 from the floor to the couch without conducting an assessment after a fall. On 3/19/16 Client 1 was hospitalized and diagnosed with a fracture of the left pelvic (hip bone). On 3/29/16 Client 1's record was reviewed. Client 1's comprehensive functional assessment dated 12/21/15 indicated she had the following diagnoses: dementia, autism, and severe intellectual disability. She was non-verbal and communicated her needs through facial gestures and grimaces. She was able to walk independently.The nursing progress notes dated 3/19/16 indicated at around 7:15 p.m., the registered nurse (RN) received a call from facility staff regarding Client 1's fall incident. DCS A and B lifted up Client 1 from the floor to the couch. Upon arrival to the facility, the RN took Client 1's vital signs. During an assessment the RN noted Client 1's back and hip area were tender when touched. The RN could not further assess the client's torso (shoulder down to the hip) especially the back area since the client was uncooperative and showed facial grimacing when her back and hips were touched. Client 1 refused to stand.The acute care hospital history and physical notes dated 3/20/16 indicated Client 1 was diagnosed status post fall with fracture of the left pelvis (hip).During observation on 3/28/16 at 9:30 a.m., Client 1 sat in her wheelchair watching television. She was awake and alert. She responded through facial expressions and could answer questions with "yes" and "no". During an interview on 3/28/16 at 10:00 a.m., the RN stated on 3/19/16 around 7:00 p.m., she received a telephone call from the facility staff who informed her Client 1 fell in the living room while ambulating. The RN stated she instructed the staff to take the client's vital signs (these are usually measured to obtain a quick evaluation of the person's general physical condition specifically the pulse rate, respiratory rate, body temperature, and blood pressure. The RN stated at 8:00 p.m., upon arrival in the facility she saw Client 1 sitting on the couch and experiencing symptoms of pain, "muscle guarding" (a protective response in the muscle that results from pain or fear of movement), and facial grimacing. The RN stated Client 1's left hip was tender when touched. The RN stated when the DCS informed her of Client 1's fall incident she forgot to give them instructions to assess the client first before transferring Client 1 to the couch.During an interview on 3/29/16 at 11:00 a.m., DCS A stated on 3/19/16 at around 7:00 p.m., she assisted another client in the living room when she saw Client 1 stand up from the couch, take a few steps and fall. DCS A stated she saw Client 1 lying on the floor. She and DCS B transferred Client 1 from the floor to the couch. DCS A stated in the process of lifting, Client 1 screamed, "Ouch"! She stated Client 1 lay with her back on the couch. DCS A stated the registered nurse was called and was informed of the incident. DCS A stated she did not conduct an assessment and neurological checks before moving the client after the fall.During another interview on 3/28/16 at 4:00 p.m., DCS B stated while preparing other clients' medications in the medication room he heard a heavy dull sound from the living room and one of the other clients yelled that somebody fell. DCS B stated he ran to the living room and saw Client 1 lying on the floor. He stated he helped DCS A to transfer Client 1 from the floor to the couch by pulling the client's pants and lifting on her armpits. DCS B stated while lifting, Client 1 yelled "ooh", made facial grimacing and resisting movement. DCS B further stated Client 1 was moaning and groaning intermittently while resting on the couch. He stated the RN was informed of the incident but no one assessed Client 1 until the RN arrived.DCS A and B both stated they did not assess Client 1 for any injury before they lifted her to the couch after the fall.During another interview on 3/28/16 at 4:30 p.m., DCS C and D stated after a client had a fall it was the facility's protocol not to move the client unless a full body assessment was conducted.During an interview on 4/15/16 at 2:07 p.m., the RN stated the course of action after a fall was to conduct a full body assessment before moving the client to determine if there were any injuries. The RN stated it was necessary not to move the client due to the possibility of further injury.The facility's undated policy and procedure, "FALLS" indicated: REMINDER-Do not move the client until you assessed. This may cause further injury. Assess before they get up, unless they get up on their own Observed fall/Unobserved fall -Assess breathing and circulation ion (check for any bleeding). Do neurological check; monitor vital signs every fifteen minutes for one hour. - Do not move the client until you assess his status fully. Observe for signs fans symptoms weakness, pain... - Assess the client's strength and motion. Ask them if they can squeeze your fingers. -If injury is suspected make the client comfortable on the floor until the RN arrives. The facility failed to conduct a full body assessment to determine if there were any injuries when Client 1 had a fall incident. The direct care staff proceeded to move and transfer Client 1 despite Client 1's difficulty in moving which placed Client 1 at a risk for further injury. On 3/19/16 Client 1 was admitted to the hospital and diagnosed with a fracture of the left hip. The above violation had a direct or immediate relationship to the health, safety, or security of the clients. |
| 630012069 |
SHINRAI-WHITE |
070012251 |
B |
16-May-16 |
UWHB11 |
2388 |
W154 483.420(D)(3) STAFF TREATMENT OF CLIENTS The facility must have evidence that all alleged violations are thoroughly investigated. The facility failed to implement their abuse policy for one of three sampled clients (5) when a dark purplish skin discoloration on the client's right lower abdomen was not reported or investigated. Client 5's clinical record was reviewed and indicated he had diagnoses including moderate developmental disabilities, blindness, and was receiving dialysis (an artificial replacement for a loss of kidney function to remove excess water and waste from the blood) three times per week. He was alert and spoke only in his native language.The nurses notes, dated 4/18/16, indicated Client 5 had a dark purplish skin discoloration on the right side of his lower abdomen with a soft mass in the middle of the discoloration site approximately 10 centimeters (cm, a unit of measurement) by three cm by one to two cm. When palpated, the client indicated he experienced pain. The nurses note also indicated, "Unfortunately, we don't know exactly when, how did he get it but the staff said he got it during transfer for dialysis."During an office visit on 4/22/16, the physician notes indicated Client 5's bruise over his right abdomen had spread and grown larger into his right flank. The note indicated Client 5 thought he hit something during the transport but was not able to provide more history. During an observation of Client 5 with the registered nurse (RN) and direct support professional C (DSP C) on 5/2/16, at 6:20 p.m., a resolving, purplish, irregular discoloration, approximately 21 cm in length and one to two cm in width, was noted in the middle of Client 5's lower back. The discoloration on his right lower abdomen was resolved. During a concurrent interview with Client 5, interpreted by DSP C, the client stated he was hit by something during transport for dialysis and did not know how and why. During a concurrent interview with the RN, she admitted she did not investigate the incident. The facility failed to implement their abuse policy, which violated Client 5's right to be protected from an injury of unknown origin, when a dark purplish skin discoloration on the client's right lower abdomen was not reported or investigated. The above violation had a direct or immediate relationship to the health, safety, or security of the client. |
| 070000061 |
SAN JOSE HEALTHCARE & WELLNESS CENTER |
070012318 |
A |
30-Jun-16 |
R1Y211 |
5414 |
F323 - 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure one of Resident 1 had adequate supervision to prevent an accident and injuries when the facility failed to assist the resident to the bathroom for ambulation and failed to implement the toileting schedule intervention listed on her fall care plan and ordered by her physician. These failures resulted in a fall and subarachnoid hemorrhage (a bleeding in the area between the brain and thin tissue which cover the brain). Resident 1's clinical record was reviewed and indicated she was admitted with diagnoses including a history of falls and hypertension (high blood pressure). Her Minimum Data Set (MDS, an assessment tool), dated 4/6/16, indicated she had severely impaired decision making skills and required assistance from the nursing staff with activities of daily living (ADLs, bed mobility, transfer, locomotion, dressing, toileting, personal hygiene, and bathing). Resident 1's Fall Risk Assessment, dated 7/7/15, indicated she had a score of 17 (a score of 10 or above represents a high risk for falls). Resident 1's April 2016 medication administration record (MAR) indicated she was receiving Cilostazol (an anti-platelet medication that can increase the risk of bleeding). Review of Resident 1's Physical Therapy (PT) note, dated 7/18/15, indicated she could safely ambulate on a level surface for an unlimited distance using a front-wheeled walker with assistance. Her Occupational Therapy (OT) note, dated 7/18/15, indicated she could safely perform toileting with an assistive device and assistance. Review of Resident 1's physician progress notes, dated 3/20/16 and 4/2/16, indicated she was on fall precautions. Her Minimum Data Set (MDS, an assessment tool), dated 4/6/16, indicated she required assistance (staff providing weight-bearing support) with one person assistance during ADLs. Her decision-making skills were severely impaired. Review of Resident 1's care plan for falls, dated 4/12/16, indicated she had a previous fall on 4/11/16 and wanted to go to the bathroom. Her care plan intervention was to continue the toileting schedule before meals and before hours of sleep and recommended staff to follow the toileting schedule. Review of Resident 1's physician order, dated 7/20/15, indicated "toileting schedule before meals and at hours of sleep and indefinite". Review of Resident 1's Situation Background Assessment Recommendation (SBAR, a technique used to facilitate prompt and appropriate communication), dated 4/23/16, indicated certified nurse assistant D (CNA D) informed licensed vocational nurse B (LVN B) on 4/22/16 at 11:45 p.m. that he heard the sound of a walker falling and when he checked Resident 1's room, he found the resident on the floor. Resident 1 had a bump on the back of her head and was bleeding. Resident 1 stated she went to the bathroom and lost her balance. She complained of pain after the incident and was given Norco (narcotic pain medication). Resident 1's Neurological Flow Sheet, dated 4/23/16, indicated her blood pressure (pressure of blood in the circulatory system) was 183/90 (normal is 120/80) at 11:45 p.m., 183/79 at 12 a.m., and 163/76 at 12:15 a.m. Review of Resident 1's ambulance transfer record indicated she was transferred to the acute care hospital on 4/23/16, at 8:38 a.m. The History and Physical Report from the acute care hospital, dated 4/23/16 (dictated 4/23/16, signed 4/24/16), indicated she had a suspected post traumatic left sided subarachnoid and parenchymal intracranial hemorrhage (bleeding in the space between the brain and the tissue covering the brain). During an interview with LVN B on 5/5/16 at 10:30 a.m., she stated Resident 1 was alone when she went to the bathroom and fell. Review of the facility's Nursing Staffing Assignment and Sign-in Sheet dated 4/22/16 indicated CNA D was the staff assigned to Resident 1 for the shift from 11 p.m. to 7 a.m. During an interview with CNA D on 5/6/16, at 8:10 a.m., he stated Resident 1 did not have a toileting schedule. During an interview with LVN A on 5/5/16, at 2:10 p.m., she stated Resident 1 should have a toileting schedule on the medication administration record (MAR) but she was unable to find the documentation. Review of Resident 1's MAR for April 2016 showed no documentation of a toileting schedule. During an interview with the director of nursing (DON) on 5/23/16 at 12 p.m., she stated Resident 1's toileting schedule should have been documented on the MAR and the licensed nurses should instruct nursing staff to take Resident 1 to the bathroom. The DON stated Resident 1 should have been accompanied to the bathroom and the care plan should have been implemented. The facility's 3/2016 policy, "Fall Management Program", indicated the facility will implement a fall management program supporting an environment free of hazards and provide a safe environment to minimize complications associated with falls. The plan of care will also be reviewed and implemented to prevent further falls. 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. |
| 070000089 |
SKYLINE HEALTHCARE CENTER - SAN JOSE |
070012345 |
B |
28-Jun-16 |
D5PL11 |
3824 |
72541 Unusual Occurrences Occurrences such as epidemic outbreaks, poisonings, fires, major accidents, death from unnatural causes or other catastrophes and unusual occurrences which threaten the welfare, safety or health of patients, personnel or visitors shall be reported by the facility within 24 hours either by telephone (and confirmed in writing) or by telegraph to the local health officer and the Department. An incident report shall be retained on file by the facility for one year. The facility shall furnish such other pertinent information related to such occurrences as the local health officer or the Department may require. Every fire or explosion which occurs in or on the premises shall be reported within 24 hours to the local fire authority or in areas not having an organized fire service, to the State Fire Marshal. The facility failed to report an unusual occurrence to the California Department of Public Health (CDPH) when Patient 28 fell 13 feet from a facility balcony onto the concrete ground resulting in multiple fractures. Patient 28's clinical record was reviewed. Her Minimum Data Set (MDS, an assessment tool), dated 5/24/16, indicated she did not have difficulty in daily decision-making skills. Patient 28 had a physician order, dated 5/31/16, to administer Risperdal, an antipsychotic medication (classification of medication used to manage psychosis and other mental and emotional conditions) 3 milligrams (mg, unit of measurement) twice daily to treat auditory and visual hallucinations (perception in the absence of external stimulus with qualities of real perception). Patient 28's nurses note, dated 6/11/16, at 1:28 a.m., indicated a walker was parked outside on the balcony of Room A. A certified nurse assistant (CNA) saw a person lying on the ground and was moaning. Patient 28 was on the ground and "constantly" stating, "I want to die." At 1:38 a.m., Patient 28 was taken to the hospital by paramedics. The hospital's General Surgery/Trauma Progress Note, dated 6/14/16, at 10:07 a.m., indicated Patient 28 was a "suspected suicide attempt by jumping off of second story balcony" resulting in left femur (thigh) and possible right sacral (triangular bone at base of spine) fractures. The hospital's Medical Nutrition Therapy Initial Assessment Note, dated 6/4/16, at 3:21 p.m., indicated Patient 28 had acute (recent) fractures of the spine in three locations and possible hemorrhagic shock (life-threatening medical condition of low blood circulation to the tissues resulting in cellular injury and inadequate tissue function). During an observation on 6/13/16, at 3:40 p.m., the balcony of Room A was surrounded by a metal fence. A maintenance staff measured the fence at 42 inches (3 feet, 6 inches) high from the balcony floor to the top of fence. The length from the top of the parking lot fence to the ground was 161 inches (13 feet, 5 inches). During an interview on 6/13/16, at 4 p.m., the director of nurses (DON) stated Patient 28 had a rollator (walker or an assistive device used for mobility) with a seat. The DON stated the incident was not reported to CDPH. During an interview on 6/16/16, at 1:40 p.m., the medical director stated he considered the fall incident to be an unusual occurrence. The facility's 1/1996 policy, "List of Examples of Unusual Occurrences", contained examples of events which should be reported as unusual occurrences to include occurrences which constituted an interference with facility operations which affect the welfare, safety, or health of patients. The facility failed to report an unusual occurrence to the CDPH when Patient 28 fell 13 feet from a facility balcony onto the concrete ground resulting in multiple fractures. This violation had a direct or immediate relationship to the health, safety, or security of the patients. |
| 070000026 |
STONEBROOK HEALTH AND REHABILITATION |
070012422 |
B |
26-Jul-16 |
B7WZ11 |
7047 |
F323--483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide adequate supervision and assistive devices to prevent for Resident 1 from falling. The failure resulted in Resident 1 sustaining a brain hemorrhage (bleeding). Resident 1's clinical record was reviewed. Resident 1 was admitted to the facility with diagnoses including hemiplegia and hemiparesis (paralysis and weakness on one side of her body), dyskinesia (abnormal or involuntary movement), a history of intracranial vasculopathy (disease of the blood vessels in the skull), and transient cerebral ischemic attack (disruption of blood flow to the brain). Review of Resident 1's Minimum Data Sets (MDS, an assessment tool) dated 5/20/16, indicated the resident was cognitively intact and required extensive assistance (the resident is involved in activity, but staff provide weight-bearing support) with one person physical assistance for her toileting. It indicated the resident was unsteady and only able to stabilize with staff assistance when she moved from a seated to a standing position, walked, turned around, and moved on and off the toilet. Review of Resident 1's Morse Fall Risk Screen (an assessment tool) dated 5/26/16, indicated the resident's score was 90. (A score of 45 and higher is high risk of falling.) Review of Resident 1's Medication Administration Record (MAR) dated 6/2016, indicated the resident took daily aspirin (a blood thinner to prevent blood clots) and clopidogrel bisulfate (a blood thinner). One of the side effects of a blood thinner includes easy bruising and bleeding. Review of Resident 1's Nurses Notes (NN) dated 2/24/16, indicated the resident attempted to transfer from a wheelchair to her bed and fell. Review of Resident 1's NN dated 4/9/16, indicated the resident stood up with a cane, lost her balance, fell backward, hit her head, and sustained a scalp laceration (a cut), and a hematoma (a solid swelling of clotted blood within tissues). Review of Resident 1's NN dated 6/18/16, indicated the resident tried to move by herself from a bedside commode to her bed after using the bedside commode and fell on the floor. It indicated the resident complained of headache with a pain scale of 9 (a numeric pain scale identifies the severity of pain from one to ten, with ten being the most severe pain) and was transferred to an acute care hospital for evaluation. Review of Resident 1's Critical Care Progress Notes from the acute care hospital, dated 6/19/16, indicated the result of a computerized tomography scan (CT scan, a diagnostic medical test) indicated Resident 1's head had a small volume of intracranial (inside the skull) blood on the left side in back of the ear, along with a bump and scrape. Review of Resident 1's NN on 6/19/16 at 11:30 a.m., documented the resident was readmitted to the facility with a diagnosis of intracranial blood. During observations on 6/27/16 at 8:10 a.m., and 11:15 a.m., and on 6/28/16 at 7:50 a.m., and 1:05 p.m., the call button (a button to call staff for help) was next to the top side rail farthest from the door, which was on the opposite side of the bed from where Resident 1 had been sitting on the bedside commode. During an interview on 6/27/16 at 8:10 a.m., Resident 1 stated on 6/18/16, she was seated on a bedside commode for approximately 30 minutes and wanted to get up. Resident 1 said the call button was on the opposite side of the bed and she could not reach it, so she had no way to call for help. Resident 1 stated she got up, lost her balance, fell backward hitting her head on the wall, and after she hit the wall, she fell to the floor, landed on her left hand and bruised it. Resident 1 stated after she fell, she had a headache and neck pain for two to three days. During an interview on 6/27/16 at 1:55 p.m., certified nursing assistant D (CNA D) said she helped Resident 1 to situate on the bedside commode and CNA D stepped out of the room. CNA D stated no one needed to stay in the room when the resident was on the bedside commode, and the resident might not be able to use a call light since her left hand was paralyzed (partly or wholly incapable of movement). CNA D stated Resident 1's legs were weak and she could not walk well. CNA D said, on 6/18/16, while Resident 1 was on a bedside commode, CNA D cleaned a resident in another room which was across the hall. CNA D stated she heard someone calling when she was about half-way through cleaning the other resident. CNA D stated she left Resident 1 on the bedside commode for approximately 10 minutes. During another interview on 7/7/16 at 3:40 p.m., Resident 1 said she had not asked the CNA to leave the room for privacy. She stated the CNAs situated her on the bedside commode, pulled the curtain, left the room, and closed the door. During an interview on 7/7/16 at 3:50 p.m., CNA E stated when she transferred a resident to a bedside commode, she gave the resident the call button, closed the curtain, stayed outside the room with the door open. CNA E stated, when the resident had an history of falls and the resident asked her to close the bathroom door, she would explain she could not close the door for the resident's safety. During an interview on 7/7/16 at 4 p.m., CNA F stated when she assisted a resident using a bedside commode, she would give the resident the call button, close the curtain, and stay outside the room with the door open. During an interview on 7/7/16 at 4:20 p.m., CNA H stated after transferring the resident to a bedside commode, she gave the resident the call button, closed the curtain, and stayed on the other side of the curtain. CNA H said, when the resident wanted to have privacy, she stepped out of the room, but left the door open so she could watch in case the resident tried to stand up. During an interview on 7/7/16 at 4:35 p.m., the director of nursing (DON) explained, when helping a resident on a commode, the CNA should give the resident the call button, close the curtain, and if the resident is alert, the CNA can leave the room, but leave the door open, and stay near door. During a telephone interview on 7/21/16 at 11:20 a.m., the neurosurgeon (NS)'s assistant (NSA) stated the NS said Resident 1's intracranial hemorrhage was due to the 6/18/16 fall incident. Review of the manufacturer's instruction "Commodes" indicated users with limited physical capabilities should be supervised or assisted when using the commode. Review of the facility's policy "Falls Management Program" dated 3/2010, indicated the facility will provide residents with adequate supervision and assistive devices to prevent accidents. Therefore, the facility failed to provide Resident 1 adequate supervision to prevent the fall incident. The above violation had a direct or immediate relationship to the health, safety, or security of residents. |
| 070000089 |
SKYLINE HEALTHCARE CENTER - SAN JOSE |
070012574 |
B |
15-Sep-16 |
LTLC11 |
7321 |
F323 -- 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to adequately prevent an accident and injury for Resident 1. Resident 1's fall risk assessment was done inaccurately on readmission and a sensor pad alarm was discontinued because of the inaccurate fall risk assessment. Resident 1's bowel and bladder training (B&B training, a form of behavior therapy to treat or reduce urinary incontinence (a loss of control of the bladder)) was not implemented as care planned as one of the interventions to prevent a fall, and the resident was not provided assistance in a timely manner for toileting. These failures resulted in Resident 1's fall, hip fracture (broken hip), surgery, and anger. Resident 1's clinical record was reviewed. The resident was admitted to the facility on 2/10/16 with a history of falls. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 5/11/16, indicated the resident was cognitively intact and had no memory problem. Resident 1 required extensive assistance (the resident involved in activity and staff provide weight-bearing support) of one person for toileting. It indicated the resident had unsteady balance while moving on and off the toilet was and only able to stabilize with staff assistance. It further indicated she had occasional incontinence of bladder. Review of Resident 1's SBAR (situation, background, assessment, and recommendation, a communication and assessment tool used by nurses for a resident's change of condition) dated 3/20/16, indicated the resident attempted to use a bedside commode, lost her balance, and fell. Review of Resident 1's Fall Care Plan dated 3/20/2016, indicated to apply a sensor pad alarm (when a resident is about to get up from a bed, staff hear an alert and can quickly go to the resident to prevent a fall) to the resident's bed and perform B&B training to prevent another fall. There was no documented evidence the B&B training was performed. Resident 1's Incontinence Care Plan dated 5/11/16, indicated Resident 1 refused to get up to use a bathroom on schedule. There was no other documentation indicating Resident 1 was assessed for an appropriate toileting program utilizing B&B assessment tools which were required per the facility's policy. Review of Resident 1's clinical record indicated the resident was discharged on 8/8/16, readmitted to the facility on 8/12/16, and the resident's fall risk was reassessed. Review of Resident 1's Fall Risk Data Collection dated 8/12/16, indicated the total score for fall risk was "8" which meant the resident was not at high risk for falls (the total score of "10" or above represents high risk for fall). The assessment included level of consciousness, history of falls, mobility with elimination, gait, balance, medications, and predisposing disease. Review of Resident 1's Fall Care Plan initiated 2/10/16 and revised on 8/12/16, indicated the resident's sensor pad alarm in her bed was discontinued on 8/12/16. Review of Resident 1's SBAR dated 8/15/16, indicated the resident had an unwitnessed fall. Review of Resident 1's History and Physical from an acute care hospital dated 8/16/16, indicated the resident was transferred to the acute care hospital after her fall on 8/15/16 and sustained a right hip fracture. Review of Resident 1's discharge summary from an acute care hospital dated 8/19/16, indicated the resident underwent surgery to repair the fractured hip in the hospital. During an interview with nursing supervisor A (NS A) on 8/29/16 at 9 a.m., she stated Resident 1's fall risk assessment was inaccurate and the score should be "12," instead of "8." She acknowledged Resident 1 was at high risk for falls. During an interview with certified nursing assistant B (CNA B) on 8/29/16 at 11:40 a.m., she stated Resident 1 needed assistance to use a bedside commode. She stated Resident 1 should have had a bed alarm to alert staff when she tried to get up from her bed. During an interview with nursing supervisor C (NS C) on 8/29/16 at 1:15 p.m., she stated Resident 1's sensor pad alarm was removed when the resident was readmitted to the facility because of the inaccurate fall risk assessment. NS C stated the alarm would prevent Resident 1 from falling by alerting the staff when Resident 1 tried to get up from her bed. During an interview with Resident 1 on 8/29/16 at 2 p.m., she stated on 8/15/16 at night, she pushed a call light to ask for assistance to use her bedside commode but no one came to help her. The resident stated she could not hold her bladder, she decided to use a bedside commode on her own, and when she stood up she slid from her bed to the floor. She stated every time she called for help, she waited for 15 minutes for the staff to come and assist her. She stated she was angry for what had happened to her regarding her fall, the fracture requiring surgery, and not getting assistance on time for toileting. During a concurrent interview with Resident 1's responsible party (RP, a person empowered to make medical decisions for the resident), she stated on 8/15/16, she was in the facility until 9:45 p.m. and Resident 1 pressed a call light around 9:15 p.m. to ask for assistance to use a bedside commode. RP stated no staff came to help Resident 1. At 9:30 p.m., RP went to a nurse's station to ask assistance to toilet Resident 1. At 9:45 p.m., she left the facility and up until that time, no staff came to help Resident 1. At 10:15 p.m., when she was at home, a nurse called her and reported Resident 1 tried to use her bedside commode by herself and fell. During an interview with the director of nursing (DON) on 8/29/16 at 2:30 p.m., she acknowledged Resident 1's fall risk assessment on readmission was inaccurate. She stated the sensor pad alarm was discontinued because of the inaccurate fall risk assessment. DON stated Bowel and Bladder Training Form, Bladder Continence Assessment Form, and Bowel and Bladder Pattern Record were not completed to assess and initiate Resident 1's B&B training. DON stated Resident 1's B&B training was not done as care planned. Review of the facility's policy "Bowel and Bladder Assessment" dated 11/2008 and revised 1/2009, indicated B&B training is to identify causes of incontinence, to reduce the number of incontinent episodes, assist a resident in becoming continent and independent in toileting, and to promote self-esteem and dignity. The procedures included to complete Bowel and Bladder Training Form, Bladder Continence Assessment Form, and Bowel and Bladder Pattern Record. Review of the facility's policy "Fall Prevention" dated 12/1/05, indicated a fall prevention program will be developed for each resident that will provide resident care staff with creative functional strategies to prevent falls and undue injuries from such incidents, while recognizing the residents' rights and their need to maintain their highest level of functioning. Therefore, the facility failed to adequately prevent an accident and injury for Resident 1. The above violation had a direct or immediate relationship to the health, safety, or security of residents. |
| 070000026 |
STONEBROOK HEALTH AND REHABILITATION |
070012751 |
B |
23-Nov-16 |
GB3R11 |
3964 |
F332 - 483.25(m) FREE OF MEDICATION ERROR RATES OF 5% OR MORE The facility must ensure that it is free of medication error rates of five percent or greater. The facility had a 28.5% medication error rate when eight medication errors during 28 opportunities were observed during the medication passes for Residents 5, 9, and 10. These failures had the potential to jeopardize the residents' health. During an observation on 11/8/16, at 10:30 a.m., registered nurse K (RN K) administered a chewable aspirin (medication for pain, fever, and reduce the risk of stroke) 81 milligrams (mg, unit of measure) to Resident 5. RN K did not administer Resident 5's scheduled Terazosin (medication to treat male enlarged prostate organ disease) 5 mg. Review of Resident 5's physician order dated 10/26/16 indicated an order of "Aspirin EC (enteric coated, another form of aspirin that dissolves in the small intestine instead of in the stomach) Delayed Release 81 MG by mouth one time a day" and "Terazosin HCL capsule 5 MG one time a day". During an interview with RN K on 11/8/16 at 2:30 p.m., she stated she gave the wrong form of aspirin to Resident 5 and did not give the resident Terazosin because this medication was not available. During an observation on 11/8/16, at 4:45 p.m., licensed vocational nurse L (LVN L) crushed together Baclofen (medication for muscle spasm) 10 mg and Vitamin C (medication for supplement) 500 mg and dissolved these medications with 10 milliliter (ml, unit of measure) in water. LVN L administered these medications through Resident 10's gastrostomy tube (G-tube, a tube inserted through the abdomen delivering nutrition and medications directly into the stomach). LVN L poured 2.5 ml of Famotidine (medication for digestive disorder) solution, 40 mg/5 ml into Resident 10's G tube. Review of Resident 10's physician's order dated 10/16/16 indicated an order of "Baclofen 10 MG via G-Tube four times a day" and "Famotidine Solution 20 MG/2 ML 2.5 ml via G-Tube two times a day". A physician's order dated 11/3/16 indicated an order of "Vitamin C tablet 500 mg via G-Tube two times a day". During an interview with LVN L on 11/8/16, at 5 p.m., she stated she gave the wrong dose of Famotidine to Resident 10. LVN L stated she thought it was okay to crush together Baclofen and Vitamin C and mix them with water. She further stated she forgot to flush the G-Tube between each medication administration. During an observation on 11/9/16, at 8:50 a.m., LVN H administered to Resident 9 B-complex with Vitamin C (supplement medication) one tablet, Magnesium (supplement medication) 550 mg, and Timolol (eyedrop medication for glaucoma, an eye disorder) 0.5% two drops to the right eye. LVN H did not administer Resident 9's scheduled Meloxicam (medication for pain) 7.5 mg. Review of Resident 9's physician's order dated 12/24/15 indicated an order of "Vitamin B Complex Tablet one unit by mouth one time a day". Another order dated 1/8/16 indicated "Magnesium Gluconate Tablet 500 MG give one tablet two times a day"; another order dated 1/17/16 indicated an order of "Meloxicam 7.5 MG give one tablet time a day". Another order dated 12/13/15 indicated "Timolol Solution 0.5% one drop in both eyes twice a day". During an interview with LVN H on 11/9/16, at 10:35 a.m., he stated he gave the wrong B-complex vitamins, wrong dose of Magnesium, and two drops of Timolol to Resident 9's right eye. LVN H stated he did not give Resident 9's scheduled Meloxicam because the medication was not available. Review of the facility's April 2008 policy, "MEDICATION ADMINISTRATION-GENERAL GUIDELINES", indicated licensed nursing staff should administer residents' medications according to the physician's order. The facility failed to ensure it was free of a medication error rate of 5 percent or greater. This could jeopardize the residents' health. This violation had a direct or immediate relationship to the health, safety, or security of residents. |
| 070000089 |
SKYLINE HEALTHCARE CENTER - SAN JOSE |
070013097 |
B |
26-Apr-17 |
SCVX11 |
9126 |
F323 -- 483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
(d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.
(1) Assess the resident for risk of entrapment from bed rails prior to installation.
(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.
The facility failed to ensure Resident 1 received adequate supervision to prevent falls and injury. Resident 1 had a history of falls and problem behaviors, including not being redirectable (capable of changing thoughts and/or behaviors) and physical and verbal aggression to staff. The staff failed to follow their care plan to ensure Resident 1 was checked frequently, and to ensure equipment (patio chair) was safe for use. Resident 1 was not supervised when he walked to the dining/patio area and fell, sustained a broken hip, and required surgical repair. This failure caused pain and suffering to the resident.
Review of Resident 1's clinical record indicated he was admitted to the facility on XXXXXXX15 with diagnoses including dementia (loss of mental ability severe enough to interfere with normal activities of daily living) with behavioral disturbance, difficulty walking, and chorea (rapid, jerky, involuntary movements of the limbs or face). His Minimum Data Set (MDS, an assessment tool) dated 2/9/17, indicated he had short and long term memory problems, made poor decisions, required cues (prompting) and supervision for activities of daily living (ADL).
Review of Resident 1's Fall Risk Data Collection form indicated he scored 22 on 9/30/16 and 20 on 2/4/17. The form indicated a total score of 10 or above represented a high falls risk.
Review of Resident 1's non-compliant care plan, dated 4/12/16, indicated the resident had problem behaviors including refusing care, and was difficult to redirect by nursing staff as he became verbally and physically aggressive.
Review of Resident 1's at risk for falls/injury care plan, dated 2/12/16, indicated he had a history of falls, balance problems, involuntary movements, and wandered (moving around or going to different places without having a particular purpose or direction). The interventions (approaches) to prevent falls included to identify type of assistance the resident needed, provide assistance as identified with transfer and mobility, and to provide frequent visual checks.
Review of Resident 1's At Risk for Wandering Out of the Facility care plan, dated 2/12/16, indicated he had interventions of having a WanderGuard (device placed on a person's extremity that would alarm when entering a designated area), and to check the resident's whereabouts.
Review of Resident 1's clinical record indicated he fell seven times between 9/8/16 and 2/24/17. The 9/8/16, 9/17/16, and 11/6/16 falls occurred in the dining room. The 9/30/16, 1/9/17, and 2/24/17 falls occurred on the patio next to the dining room.
Review of the physical therapy progress and discharge notes, with the end of care date of 9/29/16, indicated the physical therapist recommended the resident was "not safe to ambulate (walk) with staff."
Review of the facility floor plan indicated there was an elevator in nursing station 2 and a dining room was next to the elevator. The dining room led to a patio area.
During an observation on 3/23/17 at 3:15 p.m., the dining room located near Station 2 led to a patio. The patio had two glass sliding doors, concrete flooring and was not locked. There were residents seated in dining room chairs and no staff in attendance.
During an interview at the time of the observation on 3/23/17 at 3:15 p.m., licensed vocational nurse (LVN) A stated she found Resident 1 on the patio floor off the dining room near station 2 on 2/24/17 before 7 a.m., and that the patio door was not kept locked.
Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, an assessment tool used to facilitate prompt and appropriate communication of a problem) form, dated 9/30/16 at 2:40 p.m., indicated the resident fell on the patio when a leg of the chair "suddenly" broke.
Review of the Witnessed Fall care plan, revised on 9/30/16, had preventative measures of visual checks, monitor whereabouts of the resident and have maintenance staff check the patio chair for safety.
During an interview with the Maintenance/Housekeeping Supervisor, who reviewed the maintenance log on 3/27/17 at 9:40 a.m., he stated he had no knowledge and no maintenance request of a broken patio chair.
During an interview on 3/27/17 at 9:40 a.m., certified nurse assistant (CNA) B stated Resident 1 smoked on the patio. CNA B stated his walk was "wobbly," he sometimes lost his balance, and he walked around the facility without supervision.
During an interview, on 3/27/17 at 11:15 a.m., the nursing supervisor (NS) stated Resident 1 walked around the facility independently without an assistive device (cane or walker) and would often get physically combative when staff tried to redirect him. The NS said that staff were afraid of Resident 1 and did not know where he was going when he walked. The NS stated frequent visual checks indicated to observe a resident every one to two hours.
During an interview on 3/29/17 at 7:10 a.m., the charge nurse (CN) C stated during the night shift there were a maximum of 43 residents on Station 2 with one licensed nurse and two CNAs on duty. CN C stated two CNAs worked together as a team and had several duties including making rounds, passing water pitchers, and providing incontinence care. The CN said that residents who were awake at night were grouped together in a hallway where one CNA watched them, and Resident 1, when awake at night, walked to the kitchen and elevator and he could not be closely watched.
During an interview on 3/29/17 at 7:25 a.m., CN D stated Resident 1 ambulated around the hall by himself unsupervised and was able to open the patio door. CN D recalled she was passing medications on 2/24/17 at 6:50 a.m. when an alarm sounded at the elevator. CN D stated the CNAs "maybe" checked on Resident 1, who triggered the alarm, and later left him in the dining room. CN D stated she was informed by a CNA at 7 a.m. about Resident 1 having fallen on the patio. CN D said the WanderGuard only triggered the alarm when residents passed by the elevator.
During an interview on 3/29/17 at 8:50 a.m., LVN E described Resident 1 as physically and verbally aggressive to staff, able to open the patio door, did not want to be redirected and had a history of falls last year. LVN E stated Resident 1 always went to the dining room or patio by himself and he did not like to stay still. LVN E stated when Resident 1 walked, he called for CNAs to assist and watch, and the resident would become angry when he was watched or followed by staff. LVN E stated frequent checks were indicated on the resident every 30 minutes to one hour.
During an interview on 3/29/17 at 11:10 a.m., CNA F described Resident 1 as hard to approach, that he would suddenly become angry and aggressive and she was afraid to be physically hurt by him. CNA D stated on the morning he fell (2/24/17), Resident 1 slept in late. She said an alarm sounded at 6:50 a.m. when Resident 1 passed by the Station 2 elevator. She said she and another CNA checked on Resident 1 and left him in the dining room. CNA F stated she and another CNA were in a hurry to change Resident 1's bed sheets because CNAs had to sign out by 6:53 a.m. She said when she returned to work that night, she learned Resident 1 had fallen.
During an interview on 3/29/17 at 11 a.m., the director of nurses (DON) confirmed there was no specific policy for supervision and presented a form, "EVERY 30 MINUTES SAFETY WATCH," which was to be completed for frequent visual checks. The monitoring forms were requested for Resident 1 on the days of his falls. The DON stated the forms were not part of the medical records and were not provided.
Review of the "Fall Prevention" policy, dated 11/17/18, did not address a process in place as to how residents were frequently checked or supervised.
Review of the acute care hospital "Inpatient Medicine Discharge Summary," dated 2/28/17, indicated Resident 1 was brought in for an "unwitnessed fall and found to have a left intertrochanteric fx" (hip fracture) and was taken for urgent left hip surgery.
The above violations of the regulation had a direct or immediate relationship to the health, safety, or security of residents. |
| 070000086 |
SAN TOMAS CONVALESCENT HOSPITAL |
070013159 |
B |
3-May-17 |
IRIO11 |
3807 |
F226, 483.12(b)(1)-(3), 483.95(c)(1)-(3) DEVELOP/IMPLEMENT ABUSE/NEGLECT, ETC POLICIES
483.12
(b) The facility must develop and implement written policies and procedures that:
(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,
(2) Establish policies and procedures to investigate any such allegations, and
(3) Include training as required at paragraph ?483.95,
483.95
(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in ? 483.12, facilities must also provide training to their staff that at a minimum educates staff on-
(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at ? 483.12.
(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property
(c)(3) Dementia management and resident abuse prevention.
The facility failed to implement their policy and procedure for Residents 19 and 32 when allegations of abuse were not investigated and reported to the ombudsman and the California Department of Public Health (CDPH) within 24 hours as required.
1. During an interview with Resident 19 during a quality of life assessment on 4/19/17, at 11:20 a.m., she stated during the second day of her readmission on 4/12/17, certified nurse assistant J (CNA J) made a comment and told her, "Look at you, your fat face, you're putting weight on yourself." Resident 19 reported the CNA's abusive language to social worker G (SW G) and asked SW G to keep her name confidential to prevent retaliation from CNA J.
During a phone interview with SW G on 4/20/17, at 11:16 a.m., she stated she received the report from Resident 19 and considered it verbal abuse so she reported it to the director of staff development (DSD) on 4/14/17.
During a follow-up interview with the DSD on 4/20/17, at 2:20 p.m., she stated she received written notes from SW G on 4/14/17 and she did not investigate the alleged incident because the director of nurses (DON) was also informed of the alleged verbal abuse.
During an interview with the DON on 4/20/17, at 4:20 p.m., she stated she was not aware of this verbal abuse and if she knew about it she would have investigated and reported it.
2. During an interview on 4/20/17, at 3:15 p.m., Resident 32 stated she was in the dining room sitting at a table during the evening meal about two months ago. She stated another resident was sitting at the table adjacent to her with her dinner tray. She stated a CNA was sitting next to her drinking coffee and not helping the resident eat. Resident 32 stated she asked the CNA if she was going to feed the other resident.
The following day, Resident 32 stated she reported the CNA's failure to timely feed the resident to the DSD. Later the same day, Resident 32 stated the CNA came into the dining room and yelled at her for reporting her to the DSD. Since the incident, Resident 32 stated the CNA and her friends do not serve her tray during meals.
During an interview on 4/20/17, at 3:30 p.m., with the DSD, she stated the CNA denied yelling at Resident 32. The DSD stated she did not report the alleged incident of verbal abuse to the DON or anyone else.
Review of the facility's 6/24/16 policy, "Policy and Procedure on Abuse Prevention and Reporting", indicated abuse, including verbal abuse, must be reported as soon as possible, but not to exceed 24 hours after the discovery of the incident, to the administrator of the facility, the ombudsman or local law enforcement, and the Department of Public Health Licensing Agency.
The facility failed to report and investigate the allegations of abuse to the ombudsman and the CDPH within 24 hours as required. |
| 070000089 |
SKYLINE HEALTHCARE CENTER - SAN JOSE |
070013321 |
B |
6-Jul-17 |
3JNY11 |
6072 |
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 provide supervision and adequate assistance for Residents 23 and 24, when a physical altercation occurred between the two residents in the smoking area. The incident resulted in Resident 24's fall and Resident 23's acquisition of superficial scratches on his left shoulder blade and left forearm. These failures compromised the residents' safety.
On 6/19/17, at around 5 a.m., Resident 23 went to the smoking patio and saw Resident 24 smoking in the patio. Certified nurse assistant K (CNA K) was present but left when Resident 23 came into the smoking area. According to Resident 23, Resident 24 bumped his wheelchair and tried to choke him. Resident 23 broke free and asked Resident 24 why he was physically aggressive towards him. Resident 23 claimed Resident 24 was verbally threatening stating, "I'm going to kill you", and also made false accusatory remarks directed towards him. Resident 23 stated Resident 24 came back at him a second time. At this time, Resident 23 in self-defense pushed Resident 24. Resident 24 lost his balance and fell to the floor.
Resident 24's clinical record indicated he was a 65 year old male, admitted on XXXXXXX 2016 with diagnoses including anxiety disorder (a mental disorder characterized by feelings of worry, anxiety, or fear), Parkinson's disease (a disorder of the central nervous system affecting movement, including tremors), multiple sclerosis (MS, a disease of the immune system which affects the protective covering of the nerves), schizophrenia (a chronic and severe mental disorder affecting a person's thoughts, feelings, and behavior), tobacco use, and a history of falling.
Resident 24's Minimum Data Set (MDS, an assessment tool), dated 5/7/17, indicated the resident had moderate independence with decision making but listed a family member as the responsible party (RP, individual legally responsible for decision making).
A review of Resident 24's fall risk assessment score, dated 5/7/17 was 16 (a score of 10 and above represents a high risk for fall). The fall risk assessment score after the fall on 6/19/17 was 18.
Resident 24's quarterly Safe Smoking Assessment/Evaluation, dated 5/8/17, indicated he was a safe smoker but required supervision as determined by the interdisciplinary team (IDT, a team of health professionals who meet to discuss the resident's care).
During an interview with licensed vocational nurse H (LVN H) on 6/22/17, at 7:35 a.m., she stated Resident 24 would sometimes get up early in the morning and would go out to smoke. She stated she was on duty the night of the incident but did not witness the altercation or the fall. LVN H stated Resident 24 would verbalize some delusional thoughts but no physical aggression was exhibited. She stated there should have been a CNA supervising the residents in the smoking area.
During an interview with CNA K on 6/22/17, at 3:35 p.m., she stated on 6/19/17, she escorted Resident 24 to the smoking area between 3 a.m. and 4 a.m. She stated initially Resident 24 was fine and then he started to get verbally abusive and accused her of having sex with someone. CNA K felt uncomfortable around Resident 24 and left the smoking area to report Resident 24's behavior to the supervisor. At that time, Resident 23 had already reported Resident 24's fall to the supervisor. CNA K stated someone should have stayed with the resident.
During a telephone interview with registered nurse J (RN J) on 6/23/17, at 7:35 a.m., she stated on 6/19/17, Resident 23 reported Resident 24's fall to her. She stated by the time she went to the smoking area, Resident 24 was already up in his wheelchair. Resident 24 stated he slid out of the wheelchair but did not elaborate on the details.
During an interview with Resident 24 on 6/23/17, at 10:30 a.m., he stated he was "okay" but did not want to talk about the incident. He was observed to be very sleepy in his wheelchair.
A review of the facility's Smoking Time schedule indicated the smoking schedule started at 9 a.m. to 9:15 a.m. (15 minutes duration) and repeated at every two hour intervals until 7:45 p.m. to 8 p.m.
During an interview with the director of nursing (DON) on 6/22/17, at 3:15 p.m., she stated the facility would allow a resident to smoke outside of the smoking time schedule as long as someone was with the resident for their safety.
A review of the facility's "Smoking Policy", revised on 10/2010, indicated the IDT will determine if the resident is a safe smoker and the amount of supervision needed. Safe smoking assessments will be repeated quarterly and whenever there are significant changes in the resident's condition that may affect safety while smoking.
Therefore, the facility failed to provide supervision and adequate assistance for Residents 23 and 24, when a physical altercation occurred between the two residents in the smoking area. The incident resulted in Resident 24's fall and Resident 23's acquisition of superficial scratches on his left shoulder blade and left forearm.
These failures had a direct relationship to the health, safety, or security of the residents. |
| 070000086 |
SAN TOMAS CONVALESCENT HOSPITAL |
070013423 |
B |
10-Aug-17 |
PX9011 |
6889 |
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 provide a safe environment for Resident 1, when Resident 1 was placed on her left side near the edge of her bed and fell from the bed head first as certified nursing assistant A (CNA A) was pulling on Resident 1's clothing. This failure resulted in Resident 1 sustaining a cervical (neck) fracture, a right facial fracture and a laceration of her right eyebrow.
Review of Resident 1's record was initiated on 7/27/17. Resident 1 had diagnoses of atrial fibrillation (irregular heart beat), on warfarin sodium (medication to decrease clotting of the blood) and muscle weakness.
Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 5/8/17, indicated a Brief Interview for Mental Status (BIMS) score of 12 (scores of 13 to 15 indicate the person has intact cognition, scores of 9 to 12 indicate the person has moderate impairment of cognition), was wheelchair bound and required extensive assistance from staff for activities of daily living and dressing.
Review of Resident 1's "Morse Fall Assessment Scale", dated 7/22/17, indicated she had a score of 45 (a score of 45 and higher indicates a high risk for falls).
Review of Resident 1's Physician Orders dated 6/19/17 indicated Resident 1 had two upper bed side rails and was using a low air loss mattress (LAL mattress, an alternating pressure air mattress).
Review of Resident 1's Interdisciplinary Team Post Fall Review, dated 7/24/17, indicated Resident 1 slid off of her bed as CNA A was in the process of turning her in the bed and pulling up her pants. An interview with Registered Nurse B (RN B) indicated he found the resident lying face down on the floor in a pool of blood coming from Resident 1's right eyebrow. Resident 1 was alert and verbally responsive prior to leaving for the hospital via 911 (emergency services).
Review of Resident 1's hospital History and Physical report dated 7/23/17 indicated her computed tomography scan (CT scan, uses X-rays to make detailed pictures of part of the body) of the head and cervical spine showed multiple fractures of her cervical spine and a right facial fracture. The history and physical further indicated a laceration of her right eyebrow.
During an interview with CNA A on 7/27/17 at 1:10 p.m., he stated he was dressing Resident 1 at the time she fell off the bed on 7/22/17. CNA A stated Resident 1 was lying on the edge of the bed on her left side facing him, the bed was in the high position at his waist level with the side rail down. CNA A stated he was standing in front of the resident's hips and upper legs. CNA A stated Resident 1 slipped out of the upper part of the bed head first as he pulled up her pants after the resident's incontinent care. CNA A stated Resident 1 was lying on an air mattress, which was more slippery than a regular mattress, when he moved her in the bed. CNA A stated he had not had any training about caring for someone who is lying on a LAL mattress, or about moving the resident to the center of the bed and away from the edge of the bed.
During a phone interview with CNA C on 7/31/17 at 3 p.m., he stated he was Resident 1's evening shift CNA. CNA C stated he always raised the side rail when he cared for Resident A to prevent a fall, and kept her in the center of the bed when turning her. CNA C stated he took extra precautions to prevent a fall because the LAL mattress was slippery and it would become flat under Resident 1's weight, which would make it easy to roll off if she was too close to the edge of the bed.
During an interview with the Director of Staff Development (DSD) on 7/27/17 at 2 p.m., she stated she teaches the CNAs to put the residents in the middle of the bed prior to turning them onto their side. The DSD stated CNA A should have had the side rail up to prevent Resident 1 from falling. The DSD stated she teaches the CNAs to place a pillow next to the side rail to prevent the resident from hitting their head when they are turned.
Review of the DSD's lesson plan for an inservice, dated 6/6/17, titled "Turning and Repositioning", indicated the CNAs were taught to place the resident in the middle of the bed and to place pillows inside the side rails prior to repositioning.
During an interview with the DSD on 7/31/17 at 4 p.m., she stated CNA A received an inservice similar to the one provided on 6/6/17 during his orientation in January of 2017.
The facility provided a copy of the manufacturer's instructions for Resident 1's LAL mattress. The safety information section indicated there was an increased risk of gradual movement and/or inadvertent bed exit with the use of the LAL mattress. It further indicated it would be helpful to activate the Autofirm mode (air deflates from the mattress to achieve a firm mattress for repositioning purposes).
Review of the Bedard Pharmacy and Medical Supplies Website (www.BedardMedical.com) indicated there was an increased risk of resident falls with the use of the low air loss (LAL) mattress: failure to use bed rails in a raised position could lead to accidental resident falls as air mattresses have soft edges that may collapse when residents roll to the edge of the bed.
Resident 1 was transferred to a second acute care facility on XXXXXXX17 with discharge diagnoses of multiple fractures of the cervical spine, right facial fracture, and pneumonia (infection of the lung). Resident 1 expired on XXXXXXX17, one day after transfer to the second acute care facility.
The facility failed to provide a safe environment for Resident 1, when Resident 1 was placed on her left side near the edge of her bed and fell from the bed head first as certified nursing assistant A (CNA A) was pulling on Resident 1's clothing. This failure resulted in Resident 1 sustaining a cervical fracture, a right facial fracture, and a laceration of her right eyebrow.
This failure had a direct relationship to the health, safety, or security of the resident. |
| 080000060 |
San Diego Healthcare Center |
080009027 |
B |
17-Feb-12 |
KCHC11 |
6749 |
72311(a) (1) (A) Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. The facility failed to ensure a licensed nurse assessed Patient A per facility policy after the patient fell and broke her right hip, while walking to the shower. In addition the licensed nurse failed to report the fall to the oncoming shift and failed to notify the patient's physician or responsible party of the accident in a timely manner. As a result, Patient A, who could not communicate her needs, was not assessed or medicated for pain for eleven hours. Following the assessment, Patient A was transferred to the emergency room where she was diagnosed and treated for the broken hip. Patient A, a 66 year old female, was admitted to the facility on 10/21/11, with diagnoses that included Pick's disease (a rare and permanent form of dementia that is similar to Alzheimer's disease and features symptoms of language disturbance, including difficulty making or understanding speech) per the face sheet.The facility assessed Patient A with unclear speech, rarely was understood, and rarely or never understood direct person to person communication, per the quarterly MDS (Minimum Data Set) assessment dated, 4/27/11. In addition, Patient A was assessed to have short-term and long-term memory problems, and was severely impaired in cognitive skills for daily decision making. Patient A was able to ambulate with a one person assistance.Care Team Meeting notes, dated 7/1/11, contained documentation indicating that the patient fell on the morning of 6/30/11, while ambulating to the shower. According to the documentation, the patient, "Started walking towards door and her foot slipped on the floor," causing the patient to, "Sit on the floor, semi-squatting position."There was no documentation in the nursing notes to indicate a licensed nurse assessed the patient after her fall on the morning of 6/30/11, nor was there a completed Falls Investigation Worksheet, per facility policy. The facility policy, dated May 2008, titled Fall Prevention and Management Program, included, "The nurse is to assess a patient after a fall to include at a minimum: observe and palpate for injury, such as bumps, limps in unnatural positions (e.g. shortening, external rotation, fracture) assess pain, tenderness, swelling, bruising, and ROM (Range of Motion)." In addition, "Licensed Nurses are to notify attending the Physician, Responsible Party, and document all falls on the 24-hour report." Per the policy, the nurses were also responsible to, "Document pertinent information related to the fall, condition of the resident, and report the occurrence to the on-coming shift."Licensed Nurse (LN) 1 stated on 8/22/11 at 9:30 A.M., that he was getting ready to leave the morning of 6/30/11 about 7:30 A.M., when he noticed a Certified Nursing Assistant (CNA) coming out of the shower room, asking for assistance. LN 1 said he went into the shower room and found Patient A sitting on the floor. LN 1 assessed Patient A by, "Looking at her," and not per the facility protocol. LN 1 stated, "Since she was walking," He did not take the patient's vital signs or assess the patient for any injuries. LN 1 acknowledged he failed to document the patient's fall or report the fall to the oncoming shift. LN 1 stated Patient A could not talk and could not have told the staff she was in pain. CNA 1 stated on 8/22/11 at 11:10 A.M., that on the morning of 6/30/11 at approximately 7:30 A.M., she assisted Patient A to the shower room. While assisting Patient A into the shower the patient lost her balance. Patient A fell to the floor, landing in a squatting position.CNA 1 said that LN 1 stated, "She's OK," and he told CNA 1 to continue giving the patient a shower.Patient A's Responsible Party (RP) stated on 7/7/11 at 9:30 A.M., she received a call from the facility on 6/30/11, at approximately 8:30 P.M., stating Patient A was transferred to the emergency room for evaluation of hip pain. The RP further stated that she was not aware her mother had fallen on 6/30/11, until informed by facility staff on 7/1/11. When was asked if her mother could communicate she was in pain, the RP stated, "No, she can't talk. She can't tell you anything."LN 2 stated on 8/30/11 at 11:00 A.M., she was working the evening shift of 6/30/11, when at approximately 7 P.M. she was informed that Patient A was limping. LN 2 stated she did not know the patient had fallen that morning. LN 2 said she examined Patient A in her bed. LN 2 stated, "I noticed that her right leg was shorter than her left. When I tried moving her right hip, she put her hand down by her right hip. She was also grimacing, when I moved her right leg."LN 2 called the patient's physician, who gave orders to transfer the patient to the emergency room for evaluation. The patient was transferred to the emergency room at approximately 8:35 P.M. on 6/30/11.The Director of Nursing (DON) stated on 7/7/11 at 10:30 A.M., she learned of Patient A's fall, only after initiating an investigation into Patient A's hip pain and transfer to the emergency room. According to the DON, she was informed by LN 1 on 7/1/11, Patient A had fallen on the morning of 6/30/11. According to the DON, LN 1 did not document the fall, notify the attending physician, or report the fall to the on-coming shift.The Emergency Department report, dated 6/30/11, contained the following documentation: "Diagnosis: Comminuted right intertrochanteric fracture (a fracture, in which the neck of the thigh bone is broken, splintered or crushed into a number of pieces). Per Registered Nurse notes dated 6/30/11 and timed 9:01 P.M., "Behavioral cues indicate pain. Quality: Touch Sensitive." Patient A was not assessed for injury after the patient fell getting into the shower on 6/30/11, at approximately 7:30 A.M. The licensed nurse failed to notify the oncoming shift, the patient's physician and the patient's Responsible Party of the fall. This failure resulted in an eleven hour delay in recognizing the patient had sustained a fractured hip during the fall. During that time, Patient A, who was unable to tell staff if she had pain, received no medication for pain and no treatment for the injury. The violations had a direct relationship or immediate relationship to the health, safety, or security of the patient. |
| 090000063 |
San Diego Post-Acute Center |
090009355 |
B |
07-Jun-12 |
UNR811 |
17442 |
72315 (e) (f) (1-7) Nursing Service -Patient Care. (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by physician's orders. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient. (2) Encouraging, assisting and training in self-care and activities of daily living. (3) Maintaining proper body alignment and joint movement to prevent contractures and deformities. (4) Using pressure-reducing devices where indicated. (5) Providing care to maintain clean, dry skin free from feces and urine. (6) Changing of linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine. (7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician, when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). 72311(a) (1) (A) (B) (C) (2) Nursing Service -General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.72527(a) (3) (5) (6) (c) (d) 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: (3) To be fully informed by a physician of his or her total health status and to be afforded the opportunity to participate on an immediate and ongoing basis in the total plan of care including the identification of medical, nursing and psychosocial needs and the planning of related services. (5) To receive all information that is material to an individual patient's decision concerning whether to accept or refuse any proposed treatment or procedure. The disclosure of material information for administration of psychotherapeutic drugs or physical restraints or the prolonged use of a device that may lead to the inability to regain use of a normal bodily function shall include the disclosure of information listed in Section 72528(b). (6) To be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. (c) If a patient lacks the ability to understand these rights and the nature and consequences of proposed treatment, the patient's representative shall have the rights specified in this section to the extent the right may devolve to another, unless the representative's authority is otherwise limited. The patient's incapacity shall be determined by a court in accordance with state law or by the patient's physician unless the physician's determination is disputed by the patient or patient's representative. (d) Persons who may act as the patient's representative include a conservator, as authorized by Parts 3 and 4 of Division 4 of the Probate Code (commencing with Section 1800), a person designated as attorney in fact in the patient's valid durable power of attorney for health care, patient's next of kin, other appropriate surrogate decision maker designated consistent with statutory and case law, a person appointed by a court authorizing treatment pursuant to Part 7 (commencing with Section 3200) of Division 4 of the Probate Code, or, if the patient is a minor, a person lawfully authorized to represent the minor.The facility failed to ensure that a vulnerable dementia patient who was at high risk for skin breakdown, received adequate care and services to prevent the development and progression of pressure ulcers. The facility failed to adequately develop and evaluate an individualized plan of care for the patient and did not update the plan that was in place when the interventions failed. The patient or his family were not provided an opportunity to participate in the planning of the patient's care, as required. In addition, the daughter of the patient, who was the responsible party, was not informed that her father had developed multiple pressure sores at the facility. Patient A was an 85-year-old male who was admitted to the facility on 6/20/2010 with diagnoses that included: stage II decubitus ulcer (healed) urinary tract infection, general weakness and chronic pain, per the facility Admission and Discharge Summary. Pt A had both short term and long term memory deficits and his cognitive skills for daily decision making were moderately impaired and he was totally dependent on nursing staff for turning and repositioning, according to the Minimum Data Set (MDS) dated 6/30/2010.On 3/9/2011 at 8:00 A.M., Pt A was observed awake in bed and positioned on his back. There were no staff persons observed in the patient's room.On 3/9/2011 from 8:30 A.M. - 10:30 A.M., a telephone interview was conducted with the daughter of Pt A. The daughter stated her father was admitted to the facility for rehabilitation. She stated when her father was admitted to the facility he had a skin break on his buttocks that was approximately 1cm x 1cm or about the size of a 'pencil eraser'. She stated the area healed and it was the only issue with her father's skin when he was admitted to the facility. The daughter reported that on 3/2/2011 she received a telephone call from a facility doctor who told her that her father "had a wound on his back, an infection and was seriously ill and might need an amputation". She stated that was the first time that she was told that her father had a wound on his buttocks. She said the next morning her husband went to the facility and requested to look at the wounds. One of the nurses showed him all of the wounds and he took pictures and videotaped his observations.The daughter stated that her father currently had five wounds or pressure sores that developed at the facility. One wound (area 1) was on his buttocks and was approximately the size of "a hand or larger including the redness", a wound (area 2) was on the right heel of his foot and covered the entire heel, a wound (area 3) was on the left heel of his foot and covered the entire heel, a wound (area 4) was on the right big toe and (area 5) on the left big toe.The daughter reported that she made several complaints to the facility social worker in writing and in person related to the poor care that her father had received at the facility since his admission. The daughter stated that her father was frequently left in "dirty diapers" for hours, had rashes in the groin area due to the lack of care. The daughter reported her father was not repositioned in bed and was not helped by the nursing staff to get out of bed or up in a chair.The daughter stated she or her father were not provided an opportunity to participate in his plan of care and neither had attended a "Wound Management Review" meeting or signed a "Skin Status Form" that contained information related to the condition of her father's skin.On 3/9/2011 at 11:00 A.M., an interview was conducted with a certified nursing assistant (CNA) 1, who was assigned to care for Patient A. CNA 1 stated she was assigned to Patient A but did not know much about him or the care that he needed. CNA 1 stated she did not think Patient A had any skin breakdown except on his toes and said, "I am just covering."On 3/9/2011 at 11:10 A.M., an interview was conducted with Patient A's assigned licensed nurse (LN) 1. LN 1 stated that Patient A had pressure ulcers on his heels and coccyx (tailbone area) and no other areas that she knew about.On 3/9/2011 at 1:00 P.M., an interview and joint record review was conducted with a licensed nurse (LN) 3. Per LN3, Pt A did not get out of bed to sit in a wheel chair that day and reported that he was not offered the opportunity to get out of bed.LN 3, the charge nurse, stated she did not know where the CNAs documented that the patient was repositioned in bed and was observed to be unable to provide a turning and repositioning schedule for Patient A.On 3/9/2011 at 1:30 P.M., a review of patient A's clinical record was conducted. A physician's order dated 6/20/2010 indicated, "Up in chair daily as tolerated."A care plan dated 8/18/2010 indicated, "Concerns and problems: Unavoidable altered skin integrity and pressure sore ... Approach Plan: assist and encourage turning and repositioning...Keep resident's skin clean and dry at all times." The care plan was not observed to be revised or updated with alternative approaches when the original approaches failed.On 3/9/2011 at 3:50 P.M., an interview was conducted with a licensed nurse (LN) 4. LN 4 stated she did not know where the CNA was supposed to document when a patient was turned and repositioned in bed.On 3/9/2011 at 4:40 P.M., an interview was conducted with CNA 4, who was assigned to provide care for Patient A. CNA 4 was observed to attempt to find a turning and repositioning schedule for Patient A but was unable to provide it. CNA 4 stated he did not know where to document when Patient A was turned and repositioned in bed.On 3/9/2011 at 5:00 P.M., an interview and record review was conducted with the Director of Nursing (DON), Director of Staff Development (DSD) and LN 3. The DON, DSD and LN3 were all observed to search in multiple areas for a turning and repositioning schedule for Patient A and were noted to be unable to find a schedule. The DSD stated, "We are not required to keep a written turning and repositioning schedule, we leave that up to the nurses discretion."On 3/10/2011 at 10:00 A.M., a review of facility policy and procedure (P&P) entitled, "Guidelines for Assessing Potential for Pressure Sores" indicated, "...all residents with a propensity to develop pressure ulcers are placed on a turning and repositioning schedule...turning and repositioning are noted in the daily nurse assistant's notes in the resident's chart."On 3/10/2011 at 11:00A.M., an interview and joint review of Pt A's clinical record was conducted with the skin treatment nurse (LN) 2. LN 2 stated the patient refused to be repositioned when he was in bed and had refused to get out of bed and up in a wheel chair since he was admitted to the facility.A care plan dated 2/15/2011, 8 months after Pt A was admitted to the facility, indicated, "Problem & Concern: Has episodes of resistive to care aeb (as evidenced by) non-compliant with turning schedule related to multiple wounds coccyx, bilateral heels. Resident Goals: Needs will be met and no harm to self/others q (every) day x 3 mos. (months). Approach Plan: ..., refer to IDT (interdisciplinary team) prn (as needed)..."LN2 stated there had not been an IDT meeting or a "Wound Management Review" meeting with the family or the resident to discuss the wounds, to develop, review or revise the plan of care or to discuss alternative approaches related to the patient's refusals.Per LN 2, the daughter and her husband came to the facility and wanted to meet to express their concerns about the skin issues. LN 2 said, "They were actually shocked about the skin and said they did not know about it."Per LN 2, the family should always be notified of any change in status or skin issues. LN2 was observed not able to find a "Skin Status Form (s)" in Pt A's chart, which contained the signature of the family or patient, indicating they were notified. On 4/13/2011 at 9:30A.M., a review of 2 facility forms entitled, "Skin Status Form Notification and Acknowledgement" dated 11/01/2010 and 01/20/2011were reviewed with LN 2 and the social worker (SW). Both forms were not observed in Pt A's clinical record during the first record review on 3/9/2011.The form dated 11/01/2010 indicated, "(Patient Name) is a patient at (name of facility) and while at the facility has developed a pressure ulcer located on patient's L (left) big toe. The patient, responsible party and/or family member executing below has/have been informed of the foregoing and acknowledge that he/she/they understand(s) and agree(s) with the information provided herein."LN 2 acknowledged that the form did not contain the signature(s) of the patient, responsible party and/or family member to indicate that they had been notified and was observed to only be signed by LN2 and the SW.The form dated 01/20/2011 indicated, " (Patient Name) is a patient at (name of facility) and while at the facility has developed a stage II pressure ulcer located on patient's L (left) buttock extending to coccyx. The patient, responsible party and/or family member executing below has/have been informed of the foregoing and acknowledge that he/she/they understand(s) and agree(s) with the information provided herein."LN 2 acknowledged that the form did not contain the signature(s) of the patient, responsible party and/or family member to indicate that they had been notified and was observed to only be signed by LN2.On 3/10/11 at 4:00P.M., photos of Patient A's skin condition were reviewed. Photos 1-10 taken on 3/3/11, denoted stage II and greater pressure ulcers right and left great toes, Right and left heels and sacrum.On 4/13/2011 at 9:40 A.M., a review of a facility form entitled, "Wound Management Review" and dated 01/20/2011 was conducted. The form, which was not observed in Pt A's record previously, indicated, "If resident is refusing treatment or non-compliant with prescribed treatment, what alternatives were offered?" Handwritten remarks by LN2 were noted to contain no alternatives to address the reported refusals.The form was observed to contain a signature area for Nursing, Activity, Dietary, Social Services, Resident, Responsible Party and others; however the form contained only the signature of LN2. On 4/13/2011 at 10:00 A.M., an interview was conducted with the social worker (SW). The SW stated the resident had never been asked or invited to attend any facility meeting or participate in any way related to his care. The SW stated that the daughter, who was the responsible party, had not attended a facility meeting to discuss alternative approaches related to the patients care.On 4/13/2012 at 1:00 P.M., a review of facility policy and procedure (P&P) entitled, Resident Care Plan" was conducted. The P&P indicated, "1. Comprehensive Care Plan will be developed by the IDT (interdisciplinary team) and include measurable, objective and timetables to meet the residents medical nursing, mental and psychosocial needs...A).Frequency: ...2) Updated as condition changes and as revision(s) is needed...B). Participants: 1) Interdisciplinary Team...2) Resident and/or resident's representatives."In summary, the facility failed to ensure that a vulnerable dementia patient who was at high risk for skin breakdown, received adequate nursing care and services to prevent the development and progression of pressure ulcers. Patient A was observed in bed at the facility for 9 hours without being turned or repositioned by the nursing staff. The nursing staff failed to implement a physician's order to get Patient A up in a chair daily and nursing staff, including department heads, were not aware of the facility protocol for turning and repositioning. The facility failed to adequately develop and evaluate an individualized plan of care for the patient and did not implement or update the plan that was in place when the interventions failed. The patient or his family were not provided an opportunity to participate in the planning of the patient's care, as required. In addition, the facility failed to notify the daughter of the patient, who was the responsible party, that her father had multiple facility acquired pressure sores on his buttocks, heels and toes. The violation of this regulation had a direct or immediate relationship to the health, safety, or security of this patient and other patients at the facility. |
| 090000063 |
San Diego Post-Acute Center |
090009356 |
B |
07-Jun-12 |
YX2211 |
9135 |
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. 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.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 facility failed to ensure a vulnerable dementia patient (A) was free from physical and verbal abuse when a certified nursing assistant (CNA) 1 was observed to handle the patient in an abusive manner when she jerked a pillow from between the patient's legs which caused him to cry out in pain. The CNA admitted that she called the patient names when he complained about her repeated abusive treatment. In addition, the facility department heads acknowledged that they were aware of the abuse allegations and did not investigate or act upon the reports to ensure the abuse did not continue.Patient A was an 85-year-old male who was admitted to the facility on 6/20/2010 with diagnoses that included: urinary tract infection, general weakness and chronic pain, per the facility Admission and Discharge Summary. Pt A had both short term and long term memory deficits and his cognitive skills for daily decision making were moderately impaired, according to the Minimum Data Set (MDS) dated 6/30/2010.On 3/30/2011 at 8:10 A.M., an interview was conducted with the daughter of Patient A. The daughter stated that on 3/4/11, she and her mother were in her father's room and observed CNA 1 turning her father in the bed. The daughter stated CNA 1 " jerked " a pillow from between her father's legs, rolled him over then "stuffed " the pillow back between his knees. The daughter reported that her father cried out in pain and CNA 1 ignored him with no response.The daughter said that when the incident occurred, she told CNA 1 that her father "was a person not an animal" and she could not treat him that way. The daughter stated that she reported the abuse to the facility social workers on 2 occasions but there was no follow up by the facility.On 3/30/2011 at 9:15 A.M., an unannounced visit was conducted at the facility. Patient A was observed in bed and an interview was conducted in his room. Pt A stated that he had been treated "badly "by CNA 1 on a regular basis. Patient A stated the CNA was rough with him in the shower and left him uncovered and cold. Patient A stated that when he complained to CNA 1 she called him a "baby". Patient A said that on another occasion his wife and daughter saw the CNA being rough when she jerked a pillow from between his legs which caused him pain. On 3/30/2011 at 9:25 A.M., an interview was conducted with a licensed nurse (LN) 1. Per LN 1, she and CNA 1 were in Patient A's room when the family came into the room to visit. Per LN1, the CNA told the family to leave the room which led to a conflict and CNA 1 yelled at the family in front of Patient A. LN 1 stated that she felt the incident was "abusive and upsetting" to Patient A. On 3/30/2011 at 9:50 A.M., an interview was conducted with a social worker (SW) 1. Per SW 1, the family of Patient A had many concerns and complaints related to CNA 1 and submitted a written grievance report about the issues. SW 1 stated Patient A's daughter reported that she saw CNA 1 being rough with her father. SW 1 stated she did not document the conversation with the daughter and did not follow up on the abuse complaint. SW 1 stated, "She (CNA 1) is just not the warm and fuzzy type."On 3/30/2011 at 10:10 A.M., a joint review of a facility log entitled, "Grievance Report Control Log" was conducted with SW 2. The log noted multiple complaints and grievances made by facility patients and families from 3/7/2010-3/22/2011 including: "care issues", "angry re: CNAs attitude", "lack of personal care", "many issues re: care", "CNA rude to resident...", "CNA staff issues", "resident complaint re: CNA rude and rough treatment". SW 2 acknowledged that the facility did not act upon any of the possible abuse issues that were reported including the complaint from the daughter of patient A.On 3/30/2011 at 11:00 A.M., an interview and joint review of a policy and procedure (P&P) entitled, "Filing and Investigation of Grievance" was conducted with SW 2. The P&P indicated, "4. Upon receipt of a written grievance, the social services staff will provide a copy of the grievance to the Administrator and to the appropriate department manager for resolution. The department manager will investigate the complaint and submit a written report of such findings within (5) days of receiving a grievance and/or complaint. 6...the person filing the grievance will be informed of the findings." SW 2 acknowledged that the facility P&P was not followed since there was no investigation, no report and the family was not aware of any outcome.On 3/30/2011 at 11:15 A.M., a review of facility P&P entitled, "Reporting Abuse to State Agencies and Other Entities/Individuals". The P&P indicated, "All alleged/suspected violation and all substantiated incidents of abuse will be reported to DHS (California Department of Public Health) in 24 hours..." SW 1 and SW 2 stated they had not reported any of the allegations as the P&P required.On 4/1/2011 at 9:10 A.M., an interview was conducted with CNA 1. CNA 1 stated the daughter of Patient A asked that her father be placed in a wheelchair for lunch. CNA 1 stated the family was watching her take Pt A out of bed and she told them all to leave. CNA 1 stated, "Then the daughter came in and started talking crap and stuff and I just looked away. She (Patient A's daughter) said I was abusive to her father and mean to him. I don't baby him, I tell him (patient A) how it is and I told him to stop being a baby."Before asked, CNA 1 stated the following, "I am never rough with him I always pick up his legs when I pull the pillow out, I would not be abusive like that, and you can ask anybody." CNA 1 stated that although she was very angry and she could have "put her hands on somebody" she "would not risk going back to jail or returning to the life that I had in the past for those people".On 4/1/2011 at 3:18 P.M., an interview was conducted with the wife of Patient A, who reported she came to visit her husband and CNA 1 told her in a loud voice, "You cannot be in here - so get out" and pointed to the door. The wife stated her husband repeatedly told her that CNA 1 was being rough with him. The wife stated that on 3/4/11, she and her daughter were sitting at the end of Patient A's bed and he was lying on his right side and had a pillow between his knees. The wife reported that CNA 1 grabbed the pillow and "jerked it really hard" from between his knees and Patient A's legs jerked forward and he cried out in pain. The wife stated that CNA 1 then "stuffed" the pillow back between his knees and did not attempt to lift his knees, move his legs or speak to him. The wife stated that CNA 1 left the room and her husband said, "See, I told you she was a bad person and I am being treated badly."On 4/13/2011 at 9:00 A.M., a review of two facility employee files was conducted. According to a facility form entitled, "Notice of personnel Action" a CNA (2) was suspended by the facility in February 2010 for an allegation of patient abuse.On 4/13/2011 at 9:10 A.M., an interview was conducted with the facility administrator (ADM). The ADM stated the abuse allegation against CNA 2 was not reported to the state agency and there was no investigation by the facility and CNA 2 returned to work. In addition, the ADM stated that all complaints and grievances that were listed on the facility form "Grievance Report Control Log" had not been reported to the state agency or investigated by the facility.In summary, the facility failed to ensure the rights of a vulnerable dementia patient (A) were not violated when he was physically and verbally abused by a certified nursing assistant (CNA) 1. CNA 1 was physically abusive with the 85 year-old patient and did not treat him with dignity and respect when she called him derogatory names after he complained about the abusive treatment. In addition, the facility department heads acknowledged that they were aware of the abuse allegations and did not investigate or act upon the reports to ensure the abuse did not continue.The violation of this regulation had a direct or immediate relationship to the health, safety, or security of this patient and other patients at the facility. |
| 090000107 |
South Bay Post Acute Care |
090010183 |
B |
07-Nov-13 |
FKDW11 |
10851 |
F157 ?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- (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 (i.e. a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C ) 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 (D) A decision to transfer or discharge the resident from the facility as specified in ?483.12 (a) F205 ? 483.12(b)(1)&(2) Notice of Bed-Hold Policy Before/upon Transfer Based on the comprehensive Assessment of a resident, the facility must ensure that (1) 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 and (2) 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 notify Resident A's attending physician that the resident was returning from the general acute care hospital. The facility never notified Resident A or the resident's family in advance that they would not accept the resident back after being hospitalized. Instead, Resident A returned to the skilled nursing facility and was in the lobby of the facility when the licensed nurse refused to accept Resident A back into the facility. The licensed nurse discussed the issue with the daughter of Resident A and the medical transport team in the presence of Resident A. This discussion caused Resident A to become so anxious over the event that she started to complain of chest pain. Resident A was then sent back to the general acute care hospital (GACH) via 911 and subsequently was readmitted to the hospital for 3 days.Resident A was a 90 year old female admitted to the facility on 11/8/12 with pacemaker (small device placed in the chest or abdomen to help control abnormal heart rhythms) per the Record of Admission. In addition, the history and physical (H&P-physical exam) indicated that Resident A had the capacity to understand and make decisions. An interview with licensed nurse (LN) 2 was conducted on 1/17/13 at 3:00 P.M. LN 2 stated the family member of Resident A had called the physician earlier in the morning to inform him that Resident A had complaints of facial pain and low blood sugar. According to LN 2, on 1/4/13, the physician called the facility and gave a telephone order to send Resident A to the GACH for evaluation secondary to a complaint of facial pain and low blood sugar. An interview with LN 3 was conducted on 1/17/13 at 3:30 P.M. LN 3 stated "when Resident A returned to the facility on 1/9/13 via wheelchair transport, was told by the director of nursing (DON) we could not re-admit because there was no physician to follow. During the time of discussion with the transporter and the DON, Resident A had become very anxious, had complaints of chest pain, and was sent back to the GACH via 911 the same night. Did not call the physician because the DON stated there was no assigned physician. Not sure what the admission policy was; however, all admissions and re-admissions are approved by the DON." An interview with the DON was conducted on 1/17/13 at 3:35 P.M. The DON stated that the primary physician had resigned from Resident A's case.The DON stated, "Although, Resident A was on a bed-hold, the re-admission could not occur without an assigned physician. Therefore, when LN 3 called to inform of Resident A's return to the facility, he was told we could not re-admit because there was no assigned physician to follow. Therefore, the re-admission was declined." The DON denied being aware of the other physician practice accepting the Resident A's case. The DON stated she had not contacted the medical director when Resident A returned on 1/9/13 because she had no paperwork from the GACH. An interview with the primary medical doctor (MD) 1 was conducted on 4/30/13 at 2:15 P.M. MD 1 stated that he was never contacted after he had sent Resident A to the hospital or upon return to the facility. MD 1 stated he would have resumed Resident A's care until another MD had been selected.An interview with the admissions coordinator (AC) was conducted on 4/30/13 at 4:00 P.M. The AC stated she had spoken with the family member over the phone and was told that another physician and the nurse practitioner (NP) would take over Resident A's care. The AC stated the family member reported this was confirmed by the physician's NP. The AC stated this information and the paperwork from the GACH was provided to the DON; therefore, she thought Resident A was accepted to be re-admitted that evening (1/9/13). The AC stated she had made the physician change on Resident A's Record of Admission. An interview and joint review of the form titled, "Transfer Notice (Non 30 Day)" with the social service designee (SSD) was conducted on 4/30/13 at 3:30 P.M. The Transfer Notice form was dated 1/4/13 indicated that Resident A had been transfer to a GACH and the responsible had been notified of the bed hold. The SSD stated that the family member was present when Resident A left the facility for the GACH on 1/4/13; however, could not sign the bed-hold. An interview with the admission coordinator (AC) was conducted on 4/30/13 at 4:00 P.M. The AC stated that the bed hold notice (Transfer Notice) form was mailed to the family member.A review of the facility's policy titled "Admission Procedure for Licensed Nurses" was conducted on 4/30/13 at 4:20 P.M. The policy dated 4/28/97 under procedure indicated, "8. Telephone physician to notify of admission and obtain necessary orders at that time." An interview with the administrator (ADM) was conducted on 4/30/13 at 4:30 P.M. The ADM stated that Resident A's bed-hold should have been honored upon return to the facility. The ADM stated she felt there had been miscommunication on the facility's part. The ADM acknowledged that the miscommunication and denial of the readmission was the fault of the facility.An observation and interview with Resident A and a family member (FM1) was conducted on 4/30/13 at 5:05 P.M. at skilled nursing facility B.Resident A rested in bed with both eyes closed and awakened easily when spoken to. The family member stated that there was a bed-hold when Resident A left the facility on 1/4/13. The family member stated Resident A was transferred back to the facility on 1/9/13. Resident A stated upon return to the facility for re-admission, the admission was denied. Resident A said "I had no paperwork and no physician." Resident A and FM1 both stated that "the transporter had the envelope but LN 3 refused to accept the file. "Resident A then stated, "I started to have chest pains, had anxiety and palpitations. I was feeling bad because I didn't have any place to go. Then, my family member called 911."A review of the general acute care hospital (GACH) progress note dated 1/8/13 for Resident A was conducted on 5/9/13 at 3:00 P.M. The progress note indicated, "Subjective: 01/07/13. Patient [PT] admitted with hypoglycemia (low blood sugar) (Iatrogenic) due to excessive insulin... PT needs to obtain a SNF placement... 01/08/13... Issues with SNF resolved by family. Will discharge [D/C] to skilled nursing facility [SNF-nursing home] in am."The GACH Interfacility Transfer form dated 1/9/13 indicated, "Copies information included with form: Medication record, discharge summary, other: Interfacility Transfer." The GACH Emergency Documentation indicated, "Date of Care: 01/09/2013. History of Present Illness: The patient has an extensive recent medical history including recent admission and diagnosis and discharged 8 hours prior to repeat hospital evaluation. The patient was set up for discharge to a convalescent home. On arrival to the convalescent home, today at 08:00 p.m., there was noted to be a paperwork mishap with no admitting doctor listed; convalescent home/skilled nursing facility denied admission. During this time, the patient had a repeat onset of sub-sternal chest pain that lasted for 15 minutes. The patient was sent back to ... for further evaluation." The GACH Discharge Summary indicated, "Date of Admission: 01/09/2013. Date of Discharge: 01/12/2013. The patient after episodes of hypoglycemia discharged from the hospital back to the nursing home. The patient returned the same day... and the institution did not want the patient back. The patient returned to the hospital and this time the patient developed chest pain due to the overall situation and was readmitted for 3 days ... her clinical status had compensated and the social situation was arranged and the patient was released to the skilled nursing facility at this time [another facility's name] in a short term SNF placement." Residents in skilled nursing facilities have medical conditions that put them at increased risk for psychological changes due to a change in their environment. Any resident would have sustained increased anxiety when presented with the same situation as Resident A found herself suddenly in. The skilled nursing facility in which the Resident A had known as her "home" no longer wanted her and Resident A had nowhere else to go. This directly led to Resident A's increased anxiety which caused chest pain and necessitated an emergency trip to the general acute care hospital and subsequent hospitalization.The facility failed to: 1. Implement and honor their bed-hold policy. 2. Failed to communicate with Resident A and the responsible party denial of readmission prior to Resident A's return. 3. Communicate with Resident A's primary physician to verify acceptance for the continued care upon return to the facility. 4. Notify Resident A's physician upon return to the facility for admission orders.A violation of these regulations had a direct or immediate relationship to the health, safety or security of this resident. |
| 010000060 |
Seaview Rehabilitation & Wellness Center, LP |
110008655 |
B |
12-Jan-12 |
RR4C11 |
2538 |
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 failed to report an allegation of staff to resident abuse (Resident 1) to the State survey and certification agency, with the potential for continuing abuse towards Resident 1. Resident 1's clinical records were reviewed on 12/22/10, 12/23/10, and 4/14/11. She had a degenerative disease with mental and physical decline, anxiety, restless movements, muscle weakness, and muscle spasms. During a telephone interview, on 12/21/10 at 11:55 a.m., Family Member A stated that Licensed Staff B was sexually and mentally abusing Resident 1. He stated that he complained to the facility but the issue had not been resolved. During interview, on 12/22/10 at 9 a.m., Family Member A stated that Licensed Staff B was inappropriate with Resident 1, calling her "Sweetie" and stroking her hair, and he wanted another nurse to provide care for the resident. He stated he told his concerns to Licensed Nurse C, on 12/17/10, and requested another nurse, without results. During interview, on 12/22/10 at 11 a.m., the Director of Nursing and the administrator stated that Family Member A had complained to them, the previous week, about Licensed Staff B's behaviors towards Resident 1 and the facility agreed that another nurse would always go in the room when Licensed Staff B provided care for Resident 1. They stated that the allegation had not been reported to the State survey and certification agency. Nurses notes, dated 12/31/10, indicated Family Member A "made numerous allegations about [Licensed Staff B] being sexually inappropriate" with Resident 1. Review of the facility "Abuse Prevention" policy, dated 7/1/05, indicated the Administrator shall report all alleged abuse violations to state agencies immediately or within 24 hours. During interview, on 10/13/11 at 3:30 p.m., Administrative Staff F stated she was unable to find any documented evidence that the allegations of staff to resident abuse were reported to the State licensing and certification agency. The facility failed to report the allegation of abuse, towards Resident 1, to the State licensing and certification agency, with the potential for continuing abuse. Under Health & Safety 1418.91, failure to report abuse results in a Class B citation. |
| 010000060 |
Seaview Rehabilitation & Wellness Center, LP |
110008786 |
B |
12-Jan-12 |
RR4C11 |
3398 |
72527(a)(9) 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: (9) To be free from mental and physical abuse. The facility failed to implement its "Abuse Prevention" policy to investigate allegations of staff to resident abuse (Resident 1) with the potential for continuing abuse towards Resident 1. Resident 1's clinical records were reviewed on 12/22/10, 12/23/10, and 4/14/11. She had a degenerative disease with mental and physical decline, anxiety, restless movements, muscle weakness, and muscle spasms. Review of the facility "Abuse Prevention" policy, dated 7/1/05, revealed that the facility would "ensure the resident's rights are protected" by providing a method for the "investigation of any type of alleged resident abuse." The policy indicated that there shall be evidence of investigation of alleged violation and documentation shall be kept in the Administrator's office. The "Facility Investigation Report shall be completed after the investigation is complete and provided to survey agencies when requested". During a telephone interview, on 12/21/10 at 11:55 a.m., Family Member A stated that Licensed Staff B was sexually and mentally abusing Resident 1. He stated that he complained to the facility but the issue had not been resolved. During interview, on 12/22/10 at 9 a.m., Family Member A stated that Licensed Staff B was inappropriate with Resident 1, calling her "Sweetie" and stroking her hair," and he wanted another nurse to provide care for the resident. He stated he told his concerns to Licensed Nurse C, on 12/17/10, and requested another nurse, without results. During interview, on 12/22/10 at 11 a.m., the Director of Nursing and the Administrator stated that Family Member A had complained to them, the previous week, about Licensed Staff B's behaviors towards Resident 1 and the facility agreed that another nurse would always go in the room when Licensed Staff B provided care for Resident 1. When a copy of the "Facility Investigation Report" was requested, they stated that they had no available investigation of the allegation. Social Service notes, dated 12/13/10 and signed by Administrative Staff D, indicated that Family Member A requested that Licensed Staff B be moved to another unit and "this administrator will not switch" Licensed Staff B to another unit. Nurses notes, dated 12/31/10, indicated Family Member A "made numerous allegations about [Licensed Staff B] being sexually inappropriate" with Resident 1. During interview, on 1/19/11 at 8:50 a.m., Family Member A stated that nothing had changed regarding allowing Licensed Staff B to care for Resident 1. During interview, on 10/13/11 at 3:30 p.m., Administrative Staff F stated she was unable to find any documented evidence that the allegations of staff to resident abuse were investigated.The facility failed to investigate an allegation of staff to resident abuse with the potential for continuing abuse.This violation had a direct relationship to the health, safety, and security of Resident 1. |
| 010000065 |
Sonoma Acres Care Center |
110009291 |
B |
19-Jun-12 |
N7V911 |
10984 |
72319(a) Nursing Service-Restraints-Postural Support (a) Written policies and procedures concerning the use of restraints and postural supports shall be followed. 72319(b) Nursing Service-Restraints-Postural Support (b) Restraints shall only be used with a written order of a physician or other person lawfully authorized to prescribe care. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. orders for physical restraints. 72319(d) Nursing Service-Restraints-Postural Support (d) Restraints of any type shall not be used as punishment, as a substitute for more effective medical and nursing care, or for the convenience of staff. 72319(g) Nursing Service-Restraints-Postural Support (g) Restraints shall be used in such a way as not to cause physical injury to the patient and to insure the least possible discomfort to the patient. 72319(i)(1) Nursing Service-Restraints-Postural Support (i) The requirements for the use of physical restraints are: (1) Treatment restraints may be used for the protection of the patient during treatment and diagnostic procedures such as, but not limited to, intravenous therapy or catheterization procedures. Treatment restraints shall be applied for no longer than the time required to complete the treatment. The facility violated the regulation when facility staff: 1. Failed to manage Resident 2's behaviors, of leaning / moving forward and sleeping at the edge of the bed, without using physical restraints for staff convenience, 2. Failed to write physician orders which specified the duration of the use of the restraint, 3. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 2's behavior, 4. Failed to use restraints in a way that did not cause injury, 5. Failed to follow policies and procedures for the use of physical restraints. This failure resulted in the potential for entrapment in bed rails, bruising, skin tears, falls, pain, and death. Review of the facility policy, "Use of Restraints," dated 8/07, indicated, ?Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the potential of falls."The policy indicated, "Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to treat the medical symptom..." Review of the facility policy, "Use of Restraints," dated 8/07, indicated the facility defined restraints as, "...Any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body." The policy further indicated, "Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: Using bed rails to keep a resident from voluntarily getting out of bed, as opposed to enhancing mobility while in bed..." The policy indicated documentation regarding the use of restraints included: a. A description of the resident's medical symptoms (i.e. an indication or a characteristic of a physical or psychological condition) that warranted the use of restraints; b. How the restraint use benefits the resident by addressing the medical symptom, and; c. The length of the effectiveness of the restraint time.The policy indicated care plans for residents in restraints reflected interventions that addressed the immediate medical symptom(s), the underlying problems that caused the symptom(s), and included measures taken to systematically eliminate the need for restraint use.During an observation and concurrent interview on 4/30/12 at 9:10 a.m., Resident 2 was sitting in a Geri-chair (a Geri-chair is a large heavily padded wheelchair with reclining positions, a foot rest, and tray table). A soft-belt (waist restraint) spanned Resident 2's lap and tied behind the Geri-chair. Licensed Nurse (LN) B stated Resident 2 wore the soft waist belt because she (Resident 2) had a history of falling. During an observation on 5/2/12 at 8:45 a.m., Resident 2 was seated in a Geri-chair in the facility dining room. Resident 2's upper body was reclined and her feet were elevated on the foot rest. A soft-waist belt spanned Resident 2's lap and tied behind the Geri-chair.During an interview and concurrent record review on 5/2/12 at 10:45 a.m., LN B stated facility staff restrained Resident 2 in the Geri-chair with the soft-belt because Resident 2 was previously restrained in a wheelchair (WC) with a soft-belt and tipped the WC over twice (4/1/12 and 9/26/11). LN B stated facility staff raised both full bed rails when Resident 2 was in bed because Resident 2 got out of bed and fell. "Licensed Nurses Notes," dated 4/1/12, indicated Resident 2 leaned forward in her WC, turned the WC over, and hit the bridge of her nose on another resident's Geri-chair. "Licensed Nurses Notes," dated 9/26/11, indicated Resident 2 was found on the floor and had an abrasion and swelling on the bridge of her nose and right eye. LN B stated Resident 2 "had" to wear the soft-belt in the Geri-chair because, "She will lean forward and then she's going to fall." During an interview and concurrent document review on 5/2/12 at 11:53 a.m., the Director of Nursing (DON) reviewed the facility incident log and stated Resident 2 suffered an un-witnessed fall on 9/26/11, in the facility activity area/dining room. The DON stated, "I would imagine she was in her chair because she's always in her chair." The DON stated Resident 2 was "probably" restrained with a soft-belt. The DON stated Resident 2 was restrained with the soft-waist belt in her WC and leaned forward and fell a second time on 4/1/12. Review of the clinical record on 5/2/12 at 11:09 a.m., revealed: A, "History and Physical," dated 1/20/12, which indicated Resident 2's chief complaints included Alzheimer's disease and bodily contracture. Resident 2's current diagnosis included Alzheimer's disease but did not include bodily contracture. Physician orders; 1. Soft-belt in WC for safety, dated 1/4/09, 2. May use recliner (Geri-chair) with tray or belt, dated 4/1/12, 3. Two side rails while in bed for safety due to poor safety awareness and dementia, dated 1/14/09. The physician orders did not specify the length of use of the soft belt in WC, recliner (Geri-chair) with tray or belt, or two side rails while in bed. The physician orders were not designed to lead to a less restrictive way of managing Resident 2's behavior of leaning / moving forward. A, "Side Rail Safety Assessment," dated 10/24/09 and 7/8/10, indicated staff restrained Resident 2 with full side rails due the risk, "Falling out of bed.""Licensed Nurses Notes," dated; 6/13/11- 4/30/12, Staff restrained Resident 2 in bed with both side rails up. 8/1/11- 3/26/12, Staff restrained Resident 2 in the WC with a "safety belt." 10/10/11, 1/30/12, 3/12/12, 4/30/12, Staff restrained Resident 2 in a recliner (Geri-chair) with a soft-belt. 6/21/11, Resident 2 was noted to have a large purple bruise on her right inner thigh. 9/26/11, Resident 2 was found on floor in activity area at 3:30 p.m., with a bleeding abrasion and swelling to bridge of nose and right eye. Vicodin (a narcotic pain reliever) was given and ice packs were applied for 15 minutes every hour.9/26/11 at 11:30 p.m., Resident 2 had bruising to both eyes, continued to show signs of pain. Staff administered Tylenol and ice packs to control swelling and pain. 9/27/11, Staff administered Tylenol and ice packs to control pain and swelling related to Resident 2's fall on 9/26/11. 11/30/11, Resident 2 was noted to have a bruise on her left buttock. 12/24/11, Resident 2 was noted to have a bruise on her left thigh. 1/10/12, Resident 2 was noted to have a bruise near her right eyebrow. 3/25/12, late entry for 3/21/12, Resident 2 "developed" a bruise on her left eye. 3/28/12, the physician ordered treatment for skin tears above Resident 2's left eyebrow and lip. 4/1/12 at 6 a.m., staff administered first aid to an abrasion on Resident 2's right thorax. 4/1/12 at 7:45 a.m., Resident 2 leaned forward in her WC, turned the WC over, and hit the bridge of her nose on another resident's Geri-chair. 4/1/12 at 12:45 p.m., physician orders for a Geri-chair were received after Resident 2 tipped herself over in the WC while restrained with a soft-belt. 4/2/12 at 6 p.m., Resident 2's left eye and cheek bone were bruised subsequent to her fall on 4/1/12. 4/23/12, Resident 2 was noted to have three skin tears on her right knee. A care plan titled, "Risk for Injury - Restraints," dated 3/4/09, identified a problem of need for restraint use due to recent falls, leaning forward, and sleeping at the edge of the bed. The care plan also identified goals of not having any falls for the next 90 days and not having any falls from bed. The identified problems and goals directly conflicted with the facility policy which required restraints treat a medical symptom and prohibited the use of restraints for falls. The care plan indicated facility staff restrained Resident 2 in with side rails up while in bed and a soft-belt while in Geri-chair and/or WC. The care plan did not address an immediate medical symptom, the underlying problems that caused the symptom, or measures taken to systematically eliminate the need for restraint use, per facility policy. The clinical record lacked evidence of: a. A description of the resident's medical symptoms (i.e. an indication or a characteristic of a physical or psychological condition) that warranted the use of restraints, per facility policy; b. How the restraint use benefits the resident by addressing the medical symptom, per facility policy, and; c. The length of the effectiveness of the restraint time, per facility policy.Therefore, the facility violated the regulation when facility staff: 1. Failed to manage Resident 2's behaviors, of leaning / moving forward and sleeping at the edge of the bed, without using physical restraints for staff convenience, 2. Failed to write physician orders which specified the duration of the use of the restraint, 3. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 2's behavior, 4. Failed to use restraints in a way that did not cause injury, 5. Failed to follow policies and procedures for the use of physical restraints. This failure had direct or immediate relationship to health, safety, or security of patients. |
| 010000065 |
Sonoma Acres Care Center |
110009294 |
B |
19-Jun-12 |
N7V911 |
11037 |
72319(a) Nursing Service-Restraints-Postural Support (a) Written policies and procedures concerning the use of restraints and postural supports shall be followed. 72319(b) Nursing Service-Restraints-Postural Support (b) Restraints shall only be used with a written order of a physician or other person lawfully authorized to prescribe care. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. orders for physical restraints. 72319(d) Nursing Service-Restraints-Postural Support (d) Restraints of any type shall not be used as punishment, as a substitute for more effective medical and nursing care, or for the convenience of staff. 72319(i)(2) Nursing Service-Restraints-Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. 72319(i)(2)(A) Nursing Service-Restraints-Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (A) Physical restraints for behavioral control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately to the elimination of, the behavior for which the restraint is applied. There shall be no PRN orders for behavioral restraints. 72319(i)(2)(B) Nursing Service-Restraints-Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (B) Each patient care plan which includes the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used and the time limit for the use of the method. The facility violated the regulation when facility staff: 1. Failed to manage Resident 5's behavior, without using physical restraints for staff convenience, 2. Failed to write physician orders which specified the duration of the use of the restraint, 3. Failed to write physician orders for physical restraints for behavior designed to lead to a less restrictive way of managing Resident 5's behavior, 4. Failed to develop a care plan for physical restraints for behavior which specified the behavior to be eliminated and the time limit for the use of the restraint, and 5. Failed to follow policies and procedures for the use of physical restraints. This failure resulted in the potential for entrapment in bed rails, bruising, skin tears, falls, pain, and death. Review of the facility policy, "Use of Restraints," dated 8/07, indicated, "Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the potential of falls." The policy indicated, "Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to treat the medical symptom ..." Review of the facility policy, "Use of Restraints," dated 8/07, indicated the facility defined restraints as, "...Any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body." The policy further indicated, "Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: Using bed rails to keep a resident from voluntarily getting out of bed, as opposed to enhancing mobility while in bed ..." The policy indicated documentation regarding the use of restraints included: a. A description of the resident's medical symptoms (i.e. an indication or a characteristic of a physical or psychological condition) that warranted the use of restraints; b. How the restraint use benefits the resident by addressing the medical symptom, and; c. The length of the effectiveness of the restraint time.The policy indicated care plans for residents in restraints reflected interventions that addressed the immediate medical symptom(s), the underlying problems that caused the symptom(s), and included measures taken to systematically eliminate the need for restraint use. During an observation and concurrent interview on 4/30/12 at 9:35 a.m., Resident 5 was reclined in a Geri-chair with her legs elevated (a Geri-chair is a large heavily padded wheelchair with reclining positions, a foot rest, and tray table). A soft-belt (waist restraint) spanned Resident 5's lap and tied behind the Geri-chair. Licensed Nurse (LN) B stated Resident 5 sat in the recliner and wore the soft waist belt because she (Resident 5) started "sliding."During an observation on 5/2/12 at 8:35 a.m., Resident 5 was reclined in a Geri-chair with her legs elevated. A soft-belt spanned Resident 5's lap and tied behind the Geri-chair.During an interview and concurrent record review on 5/2/12 at 10:25 a.m., LN B stated Resident 5 wore a soft-belt when she was in the Geri-chair because if she sat up she would slide out. LN B stated Resident 5 was able to walk with the assistance of two staff persons, but facility staff were not providing Resident 5 with assistance walking. LN B stated she had "never" seen Resident 5 demonstrate behavior problems in the past two years. Review of the clinical record on 5/2/12 at 9:55 a.m., revealed: A face sheet which indicated Resident 5 suffered from dementia with behavior disturbance and depression with psychosis. Physician progress notes dated, 1/21/11 - 4/18/12, indicated Resident 5's behavior had been, "best in months" and "excellent." Physician orders; 1. Walk daily, dated 1/20/12 2. Side rails while in bed, dated 8/8/09 3. Soft-belt when in WC, dated 10/18/09 The physician orders did not specify the length of use of the soft belt while in WC or side rails while in bed. The physician orders were not designed to lead to a less restrictive way of managing Resident 5's behavior. There was no physician order for the Geri-chair or soft-belt while in Geri-chair."Licensed Nurses Notes," dated; 1/5/12, skin tear left elbow, "restraint" while Out of Bed (OOB) related to dementiaand leaning forward. 1/12/12 - 3/29/12, OOB daily in WC with soft belt. 1/19/12 - 4/19/12, side rails up while in bed. 3/22/12, up in Geri-chair 4/2/12, Resident 5 found with bruising to her forehead and left cheek. 4/14/12, Resident 5 found with bruising to her nose. 4/19/12, Resident 5 was in a Geri-chair with a soft - waist belt. Walks daily with two person assist to prevent contractures to legs, tolerates well. The,"Licensed Nurses Notes," dated 1/5/12 - 4/26/12 lacked documentation which indicated Resident 5 displayed behaviors that warranted the use of restraints, per facility policy. A care plan titled, "Risk for Injury - Restraints," updated 2/12, identified the problem, need for restraint use due to confusion and dementia. The care plan also identified the goal, will not have any falls for the next 90 days. The identified problem and goal directly conflicted with the facility policy which required restraints treat a medical symptom and prohibited the use of restraints for falls. The care plan interventions indicated facility staff restrained Resident 5 with a soft-belt while in WC/Geri-chair, and side rails up while in bed. The care plan did not address an immediate medical symptom, the underlying problems that caused the symptom, or measures taken to systematically eliminate the need for restraint use, per facility policy. Additionally, the clinical record lacked evidence of: a. Full documentation of the episode leading to the use of the physical restraint, including the resident's symptoms and the conditions, circumstances, and environment associated with the episode, per facility policy; b. A description of the resident's medical symptoms (i.e. an indication or a characteristic of a physical or psychological condition) that warranted the use of restraints, per facility policy; c. How the restraint use benefits the resident by addressing the medical symptom, per facility policy, and; d. The length of the effectiveness of the restraint time, per facility policy. Therefore, The facility violated the regulation when facility staff: 1. Failed to manage Resident 5's behavior without using physical restraints for staff convenience, 2. Failed to write physician orders which specified the duration of the use of the restraint, 3. Failed to write physician orders for physical restraints for behavior designed to lead to a less restrictive way of managing Resident 5's behavior, 4. Failed to develop a care plan for physical restraints for behavior which specified the behavior to be eliminated and the time limit for the use of the restraint, and 5. Failed to follow policies and procedures for the use of physical restraints. These failures resulted in the potential for entrapment in bed rails, bruising, skin tears, falls, pain, and death. This failure had direct or immediate relationship to health, safety, or security of patients. |
| 010000065 |
Sonoma Acres Care Center |
110009295 |
B |
19-Jun-12 |
N7V911 |
14352 |
72319(a) Nursing Service-Restraints-Postural Support (a) Written policies and procedures concerning the use of restraints and postural supports shall be followed. 72319(b) Nursing Service-Restraints-Postural Support (b) Restraints shall only be used with a written order of a physician or other person lawfully authorized to prescribe care. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. orders for physical restraints. 72319(d) Nursing Service-Restraints-Postural Support (d) Restraints of any type shall not be used as punishment, as a substitute for more effective medical and nursing care, or for the convenience of staff. 72319(i)(2)(A) Nursing Service-Restraints-Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (A) Physical restraints for behavioral control shall only be used with a written order designed to lead to a less restrictive way of managing, and ultimately to the elimination of, the behavior for which the restraint is applied. There shall be no PRN orders for behavioral restraints. 72319(i)(2)(B) Nursing Service-Restraints-Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (B) Each patient care plan which includes the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used and the time limit for the use of the method. 72319(i)(2)(C) Nursing Service-Restraints-Postural Support (i) The requirements for the use of physical restraints are: (2) Physical restraints for behavior control shall only be used on the signed order of a physician or other person lawfully authorized to prescribe care, except in an emergency which threatens to bring immediate injury to the patient or others. In such an emergency an order may be received by telephone, and shall be signed within 5 days. Full documentation of the episode leading to the use of the physical restraint, the type of the physical restraint used, the length of effectiveness of the restraint time and the name of the individual applying such measures shall be entered in the patient's health record. (C) Patients shall be restrained only in an area that is under supervision of staff and shall be afforded protection from other patients who may be in the area.The facility violated the regulation when facility staff: 1. Failed to manage Resident 4's behaviors, of walking without assistance and getting out of bed, without using physical restraints for staff convenience, 2. Failed to write physician orders which specified the duration of the use of the restraint, 3. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 4's behavior, 4. Failed to follow policies and procedures for the use of physical restraints. This failure resulted in the potential for entrapment in bed rails, bruising, skin tears, falls, pain, and death. Review of the facility policy, "Use of Restraints," dated 8/07, indicated, "Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the potential of falls." The policy indicated, "Restraints may only be used if/when the resident has a specific medical symptom that cannot be addressed by another less restrictive intervention AND a restraint is required to treat the medical symptom ..." Review of the facility policy, "Use of Restraints," dated 8/07, indicated the facility defined restraints as, "...Any manual method of physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body." The policy further indicated, "Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: Using bed rails to keep a resident from voluntarily getting out of bed, as opposed to enhancing mobility while in bed ..." The policy indicated documentation regarding the use of restraints included: a. Full documentation of the episode leading to the use of the physical restraint, including the resident's symptoms and the conditions, circumstances, and environment associated with the episode; b. A description of the resident's medical symptoms (i.e. an indication or a characteristic of a physical or psychological condition) that warranted the use of restraints; c. How the restraint use benefits the resident by addressing the medical symptom; d. The length of the effectiveness of the restraint time. The policy indicated care plans for residents in restraints reflected interventions that addressed the immediate medical symptom(s), the underlying problems that caused the symptom(s), and included measures taken to systematically eliminate the need for restraint use. Review of the undated facility policy, "Merry Walker," indicated facility staff put residents in Merry Walkers when residents had a history of falls and other means of walking were not "feasible." The policy also indicated, "At no time will there be a resident in a Merry Walker for staff convenience..." During an observation and concurrent interview on 4/30/12 at 9:30 a.m., a curtain was pulled at the foot of Resident 4's bed, obstructing observation of Resident 4. Entering the room and passing the curtain at the foot of Resident 4's bed, revealed Resident 4 was unattended sleeping in bed. Full side rails were raised on both sides of Resident 4's bed. Licensed Nurse (LN) B stated the side rails were raised on Resident 4's bed because, "He (Resident 4) will get out of bed and fall." A Merry Walker (MW) was observed in the facility hallway next to the door of Resident 4's room (a Merry Walker is an enclosed framed walker, with or without a seat). LN B stated Resident 4 used the MW because he got agitated when he sat in a reclined Geri-chair (a Geri-chair is a large heavily padded wheelchair with reclining positions, a foot rest, and tray table). LN B stated she had not seen Resident 4 open the MW since facility staff started using it. During an observation on 4/30/12 at 4:15 p.m., Resident 4 was in the facility dining room, standing in the MW. Resident 4 lifted his legs, turned to the side of the MW and attempted to exit the MW (There was no mechanism for exit on the side of the MW). During an observation and concurrent interview on 4/30/12 at 4:20 p.m., the Director of Nursing (DON) asked Resident 4 to exit his MW. Resident 4 was not able to exit the MW. The DON stated Resident 4 could not get out of the MW. During an observation on in 5/1/12 at 9:24 a.m., Resident 4 was in the facility dining room seated in a MW pedaling about the room, unattended by staff. A canvas strap extended from the seat of the chair, between Resident 4's legs, and attached to the middle of a bar on the front of the MW. Resident 4 stood in the MW, facing the left side of the MW. Resident 4's right leg pulled and twisted the canvas strap, as he turned facing the left side of the MW. Resident 4 pulled at the left side frame of the MW and tried to exit the MW. (There was no mechanism for exit on the left side of the MW). During an interview on 5/1/12 at 3:50 p.m., Licensed Nurse (LN) C stated Resident 4 required assistance from one staff person to walk. LN C stated facility staff put Resident 4 in a MW instead of providing assistance with walking. LN C stated when Resident 4 was initially admitted there was no physician order for the use of the MW so facility staff restrained him in a Geri-chair with a soft-belt. LN C stated when Resident 4 sat in the Geri-chair he sometimes tried to get out, so facility staff reclined the chair to prevent Resident 4 from getting out without staff assistance. LN C stated facility staff raised the bed rails on Resident 4's bed because, "He's moving and restless." LN C stated Resident 4 shook the full raised bed rails, tried to put the bed rails down, and tried to get out of bed, "That's when we ordered the soft - belt." Review of the clinical record on 5/1/12 at 3:23 p.m., revealed: An admission History and Physical (H&P), dated 3/12/12, which indicated Resident 4 was admitted to the facility after a fall and suffered from dementia; Physician orders; 1. May use soft belt while in bed and recliner chair, poor safety awareness, dementia, 2. May use side rails; fell while in bed, poor safety awareness, dated 3/12/12, 3. MW during out of bed as a substitute for the reclining chair, dated 3/20/12, 4. May ambulate in MW, dated 4/4/12, The physician orders did not specify the length of use of the soft belt while in recliner (Geri-chair), side rails while in bed, or the MW. The physician orders were not designed to lead to a less restrictive way of managing Resident 4's behavior."Licensed Nurses Notes," dated; 4/6/12 - 4/22/12, Resident 4 slept in bed with side rails up and/or a soft waist restraint. 3/26/12 - 4/22/12, Resident 4 walked in a MW 3/12/12 at 10:45 p.m., Resident 4 was admitted to the facility. Resident 4's skin was clear, without redness or breakdown. Both bed rails were raised for, "safety."3/19/12 at 10:30 p.m., Resident 4 was restless and removed his adult undergarment, "Restraint is given and continue to monitor." 3/24/12 at 10:30 a.m., "Right elbow abrasion." 3/30/12, "Resident awakens frequently at night and attempts to get OOB (out of bed) and removes clothes. Resident (4) can be non-compliant and/or combative. Soft lap belt and 2 side rails are used for safety." 4/2/12, Resident 4 was, "Noted to have 5 small bruises to 'RT' (right) inner forearm." 4/6/12, Resident 4 was restrained in a reclining chair with a soft waist belt, when he tipped the chair over backwards. Resident 4 was discovered lying on the floor, re-opened a previous injury to his elbow, and was bleeding. 4/15/12, Resident 4 found with a skin tear on his wrist. 4/22/12, Resident 4 found with a skin tear on his left wrist, first aid given. 4/27/12, Resident 4 had bruising and skin tears to arms. 5/1/12, Resident 4 found with multiple skin tears on his left calf. A, "Screening Guide for the Use of Restraints," dated 3/12/12 and completed by the DON, indicated raised bed rails, MW, and recliner were used for the, "Health Problem/Diagnosis with increased risk of falls: Dementia." A, "Screening Guide Update," dated 4/4/12 and authored by the DON, indicated an order for a MW was obtained. A, "Screening Guide Update," dated 4/6/12 and authored by the DON, indicated facility staff put Resident 4 in a reclining chair, "for safety," when he got tired. A care plan titled, "Risk for Injury - Restraints," dated 3/15/12, identified the problem, need for restraint use due to recent falls and dementia. The care plan also identified the goal, will not have any falls for the next 90 days. The identified problem and goal directly conflicted with the facility policy which required restraints treat a medical symptom and prohibited the use of restraints for falls. The care plan interventions indicated facility staff restrained Resident 4 in a MW, a Geri-chair, soft-belt while in Geri-chair, and side rails up while in bed. The care plan did not address an immediate medical symptom, the underlying problems that caused the symptom, or measures taken to systematically eliminate the need for restraint use, per facility policy. Additionally, the clinical record lacked evidence of: a. Full documentation of the episode leading to the use of the physical restraint, including the resident's symptoms and the conditions, circumstances, and environment associated with the episode, per facility policy; b. A description of the resident's medical symptoms (i.e. an indication or a characteristic of a physical or psychological condition) that warranted the use of restraints, per facility policy; c. How the restraint use benefits the resident by addressing the medical symptom, per facility policy, and; d. The length of the effectiveness of the restraint time, per facility policy. Therefore, The facility violated the regulation when facility staff: 1. Failed to manage Resident 4's behaviors, of walking without assistance and getting out of bed, without using physical restraints for staff convenience, 2. Failed to write physician orders which specified the duration of the use of the restraint, 3. Failed to write physician orders for physical restraints designed to lead to a less restrictive way of managing Resident 4's behavior, 4. Failed to follow policies and procedures for the use of physical restraints.These failures resulted in the potential for entrapment in bed rails, bruising, skin tears, falls, pain, and death. This failure had direct or immediate relationship to health, safety, or security of patients. |
| 010000065 |
Sonoma Acres Care Center |
110009296 |
B |
19-Jun-12 |
N7V911 |
3779 |
72551(a) External Disaster and Mass Casualty Program (a) A written external disaster and mass casualty program plan shall be adopted and followed. The plan shall be developed with the advice and assistance of county or regional and local planning offices and shall not conflict with county and community disaster plans. A copy of the plan shall be available on the premises for review by the Department. 72523(a) Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility violated the regulation when staff failed to follow an external disaster plan and policies and procedures for the maintenance and storage of emergency food and water supplies which indicated the facility: 1. Maintain a three day emergency food supply on the premises, and 2. Stored a three day emergency water supply. These failures resulted in the potential for illness, subsequent disease and death due to inadequate food and water supply in the event of emergency or disaster. 1. During an observation and concurrent interview on 4/30/12 at 10:30 a.m., the Dietary Supervisor (DS) said she was responsible for the facility's emergency food and water supply. The DS stated the emergency food and water supply was meant to furnish enough food for 48 people for three days. The DS stated the facility didn't currently have an adequate emergency food supply. Observation of the three day emergency food supply for 48 people and concurrent review of the, "Inventory - Emergency Menu - 3 Day," revealed: Item:Quantity needed, per MenuQuantity Observed Pears 4, #10 cans1, #10 can Pudding 4, #10 cans 2, #10 cans Beef Stew4, #10 cans 0 Three Bean Salad 2, #10 cans1, #10 Powdered Milk 20 pounds 0 Ravioli 4, #10 cans 1, #10 can Minestrone4, 52 ounce cans 0 Cornflakes2, 35 ounce bags1, 35 ounce bag When queried about the lack of emergency food supply, the DS stated, she needed to order more food. 2. During an interview on 4/30/12 at 10:30 a.m., the DS stated the facility stored one gallon of emergency water per person per day for three days, for a total of 48 persons (residents plus staff). Observation of the bottled emergency water supply on 4/30/12 at 10:30 a.m., revealed a total of 114 gallons, 30 gallons less than the calculated 144 gallons (48 persons x 1 gallon/person/day x 3 days). When queried about the deficient supply of water, on 4/30/12 at 10:30 a.m.,the DS stated the facility needed 75 gallons of emergency water, 69 gallons less than the calculated 144 gallons (48 persons x 1 gallon/person/day x 3 days). Review of the undated facility procedure, "Emergency and Disaster Procedures," revealed it was the facility policy to, "...Maintain an emergency food supply on the premises to last for a three day period." The procedure further indicated the administrator and/or dietician recommended the amount of water needed for three days. During an interview on 5/1/12 at 3:18 p.m., the Dietician stated the required food and water for the emergency supply should arrive on 5/2/12.Therefore the facility violated the regulation when staff failed to follow an external disaster plan and policies and procedures for the maintenance and storage of emergency food and water supplies which indicated the facility: 1. Maintained a three day emergency food supply on the premises, and 2. Stored a three day emergency water supply according to the facility emergency and disaster procedure. These failures resulted in the potential for illness, subsequent disease and death due to inadequate food and water supply in the event of emergency or disaster. These failures had a direct or immediate relationship to patient health, safety, or security. |
| 010000076 |
Summerfield Healthcare Center |
110009311 |
B |
04-Jun-12 |
6Y7F11 |
6481 |
F323 483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure adequate supervision to prevent one resident (Resident 1) from leaving the facility undetected. Resident 1 sustained subsequent injuries, occurring during the interval when the facility was unaware of Resident 1's absence. On 2/17/11, during record review, a document titled, "Emergency Department Summary," dated 2/15/11, indicated that at approximately 6:45 p.m., the facility was notified by a telephone call from a local hospital Emergency Department (ED) that Resident 1 was admitted after a fall. Resident 1 was found sitting on the sidewalk in front of the facility, after sunset, in the rain, at approximately 6:10 p.m. Resident 1 had been transferred by Emergency Medical Service (EMS) Ambulance, after notification to EMS by a passer-by, that an unaccompanied elderly female, complaining of ankle pain, with a hematoma on the back of her head, was found on the street. Resident 1 arrived at the ED at 6:17 p.m. The facility had been called to gain consent for permission to treat Resident 1; this intervention included a CT scan of her head without contrast medium, an Xray of her right ankle, and laboratory blood and urine tests.During an initial observation, on 2/17/11 at 9:45 a.m., the facility exit doors at the ends of hallways (which were resident-occupied) were equipped with alarms and a sign that indicated, if opened, an alarm would sound, and that these doors were attached to the wander guard sensors. The alarm system attached to the front lobby doors would also activate the wander guard sensors. However, the exit door in back of the laundry room, was equipped with an audible alarm that re-set by use of the keyboard panel on the front of the alarm box (the instructions for re-setting the code were posted above the alarm box).During an interview on 2/17/11 at 10:15 a.m., Administrative Staff A stated that Resident 1 could not recall the incident clearly, and that her short-term memory was compromised, secondary to her history of Dementia. During an interview on 2/17/11 at 11 a.m., Staff Psychiatrist B stated that Resident 1 had serious compromise of her short-term memory, however Resident 1 may be cognitive enough to re-set the alarm on the laundry room door. Staff Psychiatrist B also stated that Resident 1 has cut her wander guard off more than once.During an interview on 2/17/11 at 11:15 a.m., Resident 1 indicated she did not remember what day she hurt her ankle, but she stated that she went out of her room and [pointed around the corner to the left] out the door to get the mail, and that she walked down the sidewalk, fell and hurt her right ankle. She stated it was dark, and it was raining. Resident 1 also stated that someone helped her, and she went to the hospital. Record review of Resident 1's facility chart contained Nurses Notes, dated 2/15/11, that the facility was notified of Resident 1's elopement by phone, at 6:45 p.m., during a request for consent to treat for Resident 1. The Nurses Notes further indicated that Resident 1 had been seen at 5 p.m., when a licensed nurse documented that she had last seen Resident 1 walking on the west hall with a Certified Nurse Assistant (CNA). A document titled, "Incident/Accident Report Statements" (undated), indicated that CNA C delivered Resident 1 a dinner tray at 5:40 p.m., and that she was sitting in her chair watching television. The document also contained a statement from CNA D that he picked up Resident 1's finished dinner tray at 6:15 p.m., and that Resident 1 was out of her room. Further record review, of Resident 1's facility chart, on 2/17/11, revealed the following documents: An Admission Record, 12/21/10, which indicated Resident 1 had a diagnosis of Senile Dementia. Nurse's Notes, dated 2/3/11, which indicated that Resident 1 was having increased confusion, delusions and hallucinations, and that she went outside the facility that morning. Nurse's Notes, dated 2/5/11, which indicated that Resident 1 was having increased agitation and confusion, and that she had attempted to leave the facility twice. A Fall Risk Assessment, with the most recent date of 2/22/11, which indicated a score of 17 (a score above ten indicated a high risk for falls). A care plan for, "Admission/ADL's" (Activities of Daily Living), dated 11/3/10, which indicated that Resident 1 had acute delirium (a temporary mental state of restlessness, hallucinations). One approach for the care plan was to, "Ensure Safety." A care plan for, "Cognitive Loss," dated 11/15/10, which indicated Resident 1 had a history of paranoia, anxiety, and agitation, that her mentation fluctuated and that she was a wanderer.The care plan also indicated Resident 1 had impaired communication and noted that she reverted back to her primary language (Korean), when agitated.A care plan for, "Risk For Injury," which indicated Resident 1 was a wanderer, an elopement risk, was impulsive, has removed her wander guard and personal alarms and required 1:1 supervision, as needed. The care plan also indicated Resident 1 did not have glasses, and that she stated that her vision was poor. One of the approaches was for, "1:1 supervision as needed." Resident 1's medical record also contained a Sonoma County Emergency Dept., "ED Summary," which indicated that Resident 1 was found sitting on the sidewalk in the rain, and that the facility was called by a passer-by. The document indicated that Resident 1 had a hematoma (a swelling), with a small amount of blood, to the back of her head, as well as a fractured ankle, with a pain intensity of six on a scale of zero through ten. The facility's failure to adequately supervise Resident 1, who had attempted to leave the facility twice, ten days prior to her elopement, and actually left the facility unsupervised, twelve days prior to her elopement, resulted in her being found alone on the sidewalk, in the dark and in the rain, with a head injury and a broken ankle. Resident 1 was last seen at approximately 5:40 p.m., and the facility was alerted to her whereabouts by the local hospital at 6:45 p.m., over an hour after Resident 1 went missing. The above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 110000233 |
Sonoma Valley Hospital D/P SNF |
110009620 |
B |
06-Dec-12 |
PG5Q11 |
10104 |
1418.21(a)(1)(A) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations, in the facility: (A) An area accessible and visible to members of the public. 1418.21(a)(1)(B) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations, in the facility: (B) An area used for employee breaks. 1418.21(a)(1)(C) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (1) The information shall be posted in at least the following locations, in the facility: (C) An area used by residents for communal functions, such as dining, resident council meetings, or activities. 1418.21(a)(2)(A) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order: (A) The full name of the facility, in a clear and easily readable font of at least 28 point. 1418.21(a)(2)(B) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order: (B) The full address of the facility in a clear and easily readable font of at least 20 point. 1418.21(a)(2)(C) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order: (C) The most recent overall star rating given by CMS to that facility, except that a facility shall have seven business days from the date when it receives a different rating from the CMS to include the updated rating in the posting. The star rating shall be aligned in the center of the page. The star rating shall be expressed as the number that reflects the number of stars given to the facility by the CMS. The number shall be in a clear and easily readable font of at least two inches print. 1418.21(a)(2)(D) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order: (D) Directly below the star symbols shall be the following text in a clear and easily readable font of at least 28 point: "The above number is out of 5 stars." 1418.21(a)(2)(E) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order: (E) Directly below the text described in subparagraph (D) shall be the following text in a clear and easily readable font of at least 14 point: "This facility is reviewed annually and has been licensed by the State of California and certified by the federal Centers for Medicare and Medicaid Services (CMS). CMS rates facilities that are certified to accept Medicare or Medicaid. CMS gave the above rating to this facility. A detailed explanation of this rating is maintained at this facility and will be made available upon request. This information can also be accessed online at the Nursing Home Compare Internet Web site at. Like any information, the Five-Star Quality Rating System has strengths and limits. The criteria upon which the rating is determined may not represent all of the aspects of care that may be important to you. You are encouraged to discuss the rating with facility staff. The Five-Star Quality Rating System was created to help consumers, their families, and caregivers compare nursing homes more easily and help identify areas about which you may want to ask questions. Nursing home ratings are assigned based on ratings given to health inspections, staffing, and quality measures. Some areas are assigned a greater weight than other areas. These ratings are combined to calculate the overall rating posted here." 1418.21(a)(2)(F) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order: (F) Directly below the text described in subparagraph (E), the following text shall appear in a clear and easily readable font of at least 14 point: "State licensing information on skilled nursing facilities is available on the State Department of Public Health's Internet Web site at: www.cdph.ca.gov, under Programs, Licensing and Certification, Health Facilities Consumer Information System." 1418.21(a)(3) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (3) For the purposes of this section, "a detailed explanation of this rating" shall include, but shall not be limited to, a printout of the information explaining the Five-Star Quality Rating System that is available on the CMS Nursing Home Compare Internet Web site. This information shall be maintained at the facility and shall be made available upon request. 1418.21(a)(4) Health & Safety Code 1418 (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements: (4) The requirements of this section shall be in addition to any other posting or inspection report availability requirements. 1418.21(b) Health & Safety Code 1418 (b) Violation of this section shall constitute a class B violation, as defined in subdivision (e) of Section 1424 and, notwithstanding Section 1290, shall not constitute a crime. Fines from a violation of this section shall be deposited into the State Health Facilities Citation Penalties Account, created pursuant to Section 1417.2. Based on observation, interview, and review of documents, the facility did not post the overall facility rating in the specified locations or in the specified format which resulted in the information being unavailable to the residents, staff and public. Findings: During an observational tour on 11/14/12 at 11 a.m. of the front lobby of the facility, there was no posting of the overall rating of skilled nursing facility unit. During an observational tour on 11/14/12 at 11:05 a.m. of the skilled nursing facility unit, there was no posting of the overall facility rating in the hallways, on the bulletin boards, or in the Dining Room/Activity Room. During an observational tour on 11/14/12 at 11:15 a.m. of the skilled nursing facility employee break room, there was no posting of the skilled nursing facility overall rating. During an interview with concurrent observation on 11/15/12 at 2 p.m., Administrative Staff A indicated a "Medicare.gov" form on the main bulletin board at the entrance to the skilled nursing facility unit titled "Nursing Home Results". The form had the name and address of the facility. In the column Overall Rating, the form had 5 orange stars and 4 grey stars in a font size smaller than a typed lower case letter. Under the stars was written "Much Above Average". Administrative Staff A indicated a copy of the same form in the binder in the Activities/Dining Room that contained the write up of the facility's Recertification Survey from 10/07/11. The form was the first page in the binder. The form was not posted anywhere in the room. The form did not meet the specified requirements for the appearance of the form or meet the requirements for the posting of the overall rating information. During an interview on 11/12/12 at 2:20 p.m., Administrative Staff A stated, "I thought it had to be on "medicare.gov" paper. I thought it had to be on official paper." Administrative Staff A stated that she thought it would be considered falsifying the information if she designed the posting herself. |
| 110000074 |
SPRINGS ROAD HEALTHCARE |
110010758 |
B |
16-Jun-14 |
UX6F11 |
2007 |
A064 1418.91(a) Health & Safety Code 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. Based on facility interview and policy review, the facility failed to follow its abuse policy and procedure by not reporting an allegation of abuse of two residents to the State Licensing and Certification Agency, California Department of Public Health (CDPH). This had the potential for continuing abuse of residents. Findings: 1. On 1/28/13, the Department received a complaint allegation indicating that on 1/23/13, Resident 2 struck Resident 1 with his cane, during a quarrel. 2. On 1/28/13, the Department received a complaint allegation indicating that on 1/24/13, Resident 3 grabbed Resident 4 around the neck. Resident 4 then reacted by throwing Resident 3 down to the ground, as a result of a miscommunication. On 2/7/13 at 1:50 p.m., upon inquiry, the Administrator stated she believed both incidents had been reported to the Department. She stated she would send the surveyor documentation. On 2/8/13, the Department received a note from the facility's Administrator, via fax and dated 2/8/13, regarding the incidents. The note indicated the facility called the Ombudsman and the Police Department regarding the incident, and that it was her understanding that they were supposed to contact the Department as well. On 5/14/14, the Administrator was asked to clarify her note as to whether or not the Department had been notified of the abuse allegations. She stated she did not and should have [reported the abuse allegation]. On 5/14/14, the facility policy and procedure, last revised on February 2007, regarding reporting of abuse allegations, indicated that events involving allegations of abuse, neglect, mistreatment, misappropriation of residents' property, or injuries of unknown source, were to be reported immediately to the state survey and certification agency. |
| 110000233 |
Sonoma Valley Hospital D/P SNF |
110011192 |
A |
30-Dec-14 |
QWH911 |
12822 |
A208 T22 DIV5 CH3 ART3-72315(f)(7) Nursing Service - Patient Care (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician, when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b). The facility violated the regulation by failing to: 1) notify the physician that Resident 1's blister was open on 5/2/14; 2) follow the facility's policy and procedure to stage the pressure sore and provide ongoing measurements; 3) reassess for alternative devices for pressure relief; and 4) obtain treatment order for the open pressure sore on 5/2/14. These failures resulted in a delay in treatment from 5/2/14 to 5/18/14 that caused Resident 1's pressure sore to progress to a stage III pressure sore (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss; may include undermining or tunneling).Findings: Resident 1's admission record revealed that Resident 1 was a 76 year old female, who was admitted to the facility on 4/16/14 for a right hip fracture. Resident 1's "Progress Record," dated 4/17/14, indicated that Resident 1 had dementia. The admission minimum data set (MDS, assessment tool), dated 4/23/14, indicated that Resident 1 did not have any pressure sore. Resident 1's Brief Interview for Mental Status (BIMS) score was 12, which indicated Resident 1 had moderately impaired cognition. Resident 1 needed extensive assistance and required two persons' physical assist for bed mobility and transfer. The MDS also indicated Resident 1 was at risk of developing pressure sores.The "Daily Assessment Inquiry," dated 4/24/14, revealed that Resident 1 developed a clear blister (A Stage II pressure sore - Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister) that measured 3 centimeter (cm) length and 3 cm width with no open area on Resident 1's right heel.A physician's telephone order, dated 4/24/14, indicated "Monitor blood blister on Rt (right) heel Q shift (every shift)..." A care plan for "Potential for Skin Breakdown," dated 4/28/14, indicated that Resident 1 had multiple problems including "...Immobility, Fragile skin..." The goal of the care plan included "Maintain skin integrity..." The approaches included "...Patient to wear heel elevators...Float heels..." During an interview on 9/2/14, at 1:45 p.m., The DON (Director of Nursing) stated that the heel protector and the "heel floater" were the same.During an interview on 7/24/14, at 3:50 p.m., Licensed Staff E stated that Resident 1 often kicked off the heel protector. Licensed Staff E stated staff reapplied the heel protector and reminded Resident 1 to keep the heel protector on. Licensed Staff E stated Resident 1 forgot and kicked off the heel protector again. Licensed Staff E stated that she did not know the specific schedule when staff were supposed to apply the heel protector on Resident 1's foot. Licensed Staff E stated that it should be in the care plan but she was not sure.During an interview on 8/28/14, at 8:50 a.m., the DON stated that Resident 1 often kicked off the heel protector because Resident 1 had dementia. She stated the alternative intervention for the heel protector was to reapplied the heel protector when the resident kicked it off. When the DON was informed that some nursing assessments and interventions did not indicate if the heel protector was applied on Resident 1's right heel, she stated nurses documented these in the nurse's notes.The nurse's progress notes provided by the facility did not indicate that protectors were put on Resident 1's right heel.The "Daily Assessment Inquiry," dated 5/2/14, indicated "Opened blister to...heel." The documents did not indicate that the facility had notified the physician when the blister had opened on 5/2/14.During an interview on 11/6/14, at 8:10 a.m., Licensed Staff F stated if she noticed an open blister, she would document the blister, take a picture, measure the wound, and notify the wound consultant. Licensed Staff F was asked what was the rationale for not doing the following for the open blister on 5/2/14: measuring the wound, taking a picture, notifying the wound consultant, and notifying the physician. Licensed Staff F stated "I do not know. I do not remember..."During an interview on 9/2/14, at 10:10 a.m., Licensed Staff C stated that if she found an open blister on a resident, she would measure the blister and notify the wound care nurse. Licensed Staff C was asked on 11/3/14, at 9:40 a.m., the reasons for not doing the following: 1) measuring the wound, and 2) notifying the wound care nurse of the open blister on 5/2/14, Licensed Staff C stated "I do not know..." The "Wound Care Record Sheet," dated 4/29/14 to 5/18/14, indicated treatment for Resident 1's right heel blister was "...Apply skin prep (Protective wipe) to Rt (right) Heel blister daily & Float Heels..."During an interview on 9/2/14, at 4:10 p.m., the DON stated the skin prep was contraindicated to an open blister. The DON stated, "I would not use skin prep." The DON stated on 9/3/14, at 2 p.m., applying skin prep to an open blister could burn and irritate the wound bed. During an interview on 9/8/14, at 10:30 a.m., the DON confirmed that the facility did not have a care plan for the right heel blister or pressure sore. She also confirmed that the care plan for potential for skin breakdown had not been revised since 4/28/14. The facility document titled "Daily Assessment Inquiry," dated 5/18/14, indicated "BLISTER TO R (right) HEEL OPEN MEASURES 2 CM x 1.5 CM. WOUND BED HAS AREAS OF PINK AND BLACK...WOUND CARE CONSULT REQUEST."During an interview and concurrent record review on 9/2/14, at 1:45 p.m., the DON stated that the nurses should notify the wound care nurse of an open blister and should measure the wound and take pictures every week. The DON stated she did not know why the open blister was not measured from 4/25/14 to 5/17/14 (23 days). The DON also stated that she did not know why the wound care nurse was not notified until 5/18/14 when the blister was opened on 5/2/14. She stated that the wound care nurse should follow up on Resident 1's wound every week.The "Progress Note Inquiry," dated 5/19/14, indicated that the Wound Care Nurse performed a sharp debridement (a procedure to remove the dead tissue from the wound) for Resident 1's right heel and documented the wound as Stage UTD (undetermined depth) pressure sore with measurement of 3.7 cm x 3.7 cm x UTD, 100% slough (dead tissue).During an interview on 9/2/14, at 9:30 a.m., Licensed Staff B stated that Resident 1's pressure sore on the right heel was at least stage III. Licensed Staff B stated he was the wound care nurse in another department and he would not see the wound again unless he was asked by the licensed staff. During an interview on 9/2/14, at 2:55 p.m., Licensed Staff B stated that the nurses should assess the wound at every dressing change and measure the wound once a week. During an interview on 9/10/14, at 11 a.m. and 2:55 p.m., Resident 1's daughter stated that Resident 1 had a surgical repair of the right hip fracture. She stated that Resident 1 could barely move her right foot and needed two persons assist. She stated Resident 1 was not able to kick off the heel protector. She also stated that she visited Resident 1 daily and only saw Resident 1 had a heel protector on for a few times. Resident 1's daughter stated Resident 1 often complained of pain on the right heel wound to the nurse. She stated that the staff did not call the doctor for the wound, so she called the doctor about the wound around May 20, 2014 (she stated she did not remember the exact date) when she saw Resident 1 had a wrap on her right foot with a bad smell. She also stated that she brought the pictures of the wound to the medical director and the medical director was horrified when he looked at the pictures. During an interview on 9/5/14, at 9:45 a.m., Physician D stated that she did not know about Resident 1's right heel sore until Resident 1's daughter left her a message concerning Resident 1's foot. Physician D stated the nurse should have notified her for a new developed pressure sore and any change of the pressure sore. Physician D stated she did not know about the wound care nurse debridement of the wound. Physician D also stated that the wound care nurse did not notify her. Physician D stated that she was not sure if she actually saw the wound because it was usually covered by a dressing. Physician D stated, "You really do not want to disturb the dressing and the wound." Physician D further stated that Resident 1 was admitted for a hip fracture, so she focused on the hip and did not pay much attention to the foot sore although physicians should be responsible for everything. During an interview on 9/9/14, at 3:20 p.m., Physician D stated that pressure on the heel was one of the factors that caused Resident 1's right heel sore. Physician D stated that the main problem on this wound was communication. Physician D stated that the nurses should communicate with her more often. Physician D stated she expected the nurses to notify her under the following circumstances: 1) Resident 1 developed a new blister, 2) identified an open blister, 3) identified family's concerns, or 4) there was any change to the wound. During an interview on 9/17/14, at 1:25 p.m., the Medical Director stated that he saw the pictures of Resident 1's right heel wound. He stated that the wound was a significant deep pressure sore, which was at least Stage III. During an interview on 9/8/14, at 10:30 a.m., the DON confirmed that the facility had no measurements for the wound on the following dates: 4/25/14 to 5/17/14 (23 days), 5/20/14 to 5/28/14 (9 days), and 6/2/14 to 6/10/14 (9 days). The policy and procedure titled "Lippincott Procedures - Pressure ulcer prevention," dated 1/10/14, indicated "...Update the care plan, as required. On the clinical record, document a complete skin assessment and interventions used to prevent pressure ulcers and the patient's response. If a pressure ulcer develops, note changes in the condition or size of the pressure ulcer and elevation of skin temperature. Document when the doctor was notified of pertinent abnormal observations..."The facility policy titled "Pressure Ulcer & Wound Care Assessment and Management," dated 3/14, indicated "All wounds will be assessed upon admission and/or occurrence, then weekly to measure progress & response to intervention. Pressure ulcers will be classified according to stage...Documented assessments will include: 1. Location of wound 2. Type of wound (i.e. pressure ulcer, skin tear, venous or arterial leg wound, etc). 3. Stage wound FOR PRESSURE ULCERS ONLY 4. Sized of wound (length X width X depth in cm). 5. Color of wound (percentage of pink/red (healthy) tissue and percentage of yellow, black, white tissue, etc). 6. Description of periwound tissue (macerated, erythematous, etc). 7. Presence or absence of discharge-characteristics (i.e. 'light amount of yellow purulent'). 8. Presence or absence of odor. 9. Presence of any undermining or tunneling (i.e. '2cm of undermining from 3-6 o'clock'). 10. Assess pain from wound A wound treatment plan will be initiated for a patient at the time of admission or upon development of a wound. The patient's treatment plan will be evaluated every day in acute care & every week in SNF (skilled nursing facility) and revised as necessary... Wound Management A. Establish realistic goals related to wound management in collaboration with the patient, family, caregivers and physician...if wound healing IS realistic goal, the following interventions should be incorporated into the care plan..." Therefore, The facility violated the regulation by failing to: 1) notify the physician that Resident 1's blister was open on 5/2/14; 2) follow the facility's policy and procedure to stage the pressure sore and provide ongoing measurements; 3) reassess for alternative devices for pressure relief; and 4) obtain treatment order for the open pressure sore on 5/2/14. These failures resulted in a delay in treatment from 5/2/14 to 5/18/14 that caused Resident 1's pressure sore to progress to a stage III pressure sore. The violation of the regulation had presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 110000233 |
Sonoma Valley Hospital D/P SNF |
110011193 |
A |
30-Dec-14 |
H3DN11 |
4935 |
A166 T22 DIV5 CH3 ART3-72311(a)(2) Nursing Service -General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.The facility violated the regulation by failing to implement Resident 1's care plan for fall precaution. This failure caused Resident 1 to sustain a left hip fracture after falling while getting up unassisted from the toilet in the bathroom and required Resident 1 to undergo a left hip surgery. Findings: Resident 1's admission record indicated that Resident 1, a 94 year old female, was admitted to the facility on 4/2/13 for a stroke. The fall risk evaluations, dated 4/2/13, 4/4/13, and 4/5/13, indicated that Resident 1 was at high risk for falls due to multiple problems including "...Confused/Senile...History of Falls...Unsteady of Feet..." Resident 1's care plan for safety/fall risk, dated 4/2/13, indicated that Resident 1 had impaired functional mobility, impaired cognition, and poor safety awareness. The goal of the care plan included "Absence of injury or further injury from falls." One of the intervention plans was "Do not leave patient unattended on toilet or BSC (bedside commode)." The facility investigation report, dated 4/7/13, indicated that on 4/5/13, the facility staff left Resident 1 in the bathroom unattended. The report revealed that Resident 1 fell in the bathroom while getting up unassisted from the toilet.During an interview on 10/31/14, at 3 p.m., Unlicensed Staff C stated that on 4/5/13, she assisted Resident 1 to use the toilet in the bathroom. She stated that she left Resident 1 in the bathroom and told Resident 1 to wait for her. She stated that she left the bathroom door open a crack and went to fix Resident 1's bed in the room. Unlicensed Staff C stated while she was fixing Resident 1's bed, Resident 1 got up unassisted and fell in the bathroom. When asked Unlicensed Staff C how she interpreted the intervention, "Do not leave patient unattended on toilet or BSC," on Resident 1's care plan, she stated that she would stay with Resident 1 and would not leave Resident 1 at all. She also stated that she did not know about Resident 1's intervention plan because Resident 1 was not her assigned resident. Unlicensed Staff C stated before assisting Resident 1, she asked Resident 1's assigned CNA (certified nursing assistant) if Resident 1 could use the bathroom. She further stated that the assigned CNA just told her to take Resident 1 to the bathroom. During an interview on 11/3/14, at 9:40 a.m., Licensed Staff B stated that Unlicensed Staff C should know Resident 1's care information from the hand-off CNA. When asked Licensed Staff B how she interpreted the intervention, "Do not leave patient unattended on toilet or BSC," on Resident 1's care plan, she stated that staff should not leave Resident 1 unattended. She also stated that some residents might not like a staff standing by them while using the toilet, but the staff should at least stand by the bathroom door and "visually see" the resident. She stated that the staff should be able to assist the resident when the resident attempted to get up. She further stated that the CNA could not see Resident 1 when the bathroom door was open a crack and the CNA were fixing the bed. During an interview on 12/16/14, at 8:25 a.m., Administrative Staff A was asked how she interpreted the intervention, "Do not leave patient unattended on toilet or BSC," on Resident 1's care plan dated 4/2/13. Administrative Staff A stated that the intervention was self-explanatory and she expected the staff "Do not leave the patient." She also stated that all CNAs should know about the residents because all CNAs attended the change shift report and residents had a yellow armband indicating fall risk.The acute care hospital x-ray result, dated 4/6/13, revealed that Resident 1 sustained a left hip fracture from the fall. The discharge summary, dated 4/10/13, indicated that Resident 1 was admitted to the acute care hospital on 4/7/13 and underwent a surgical repair of the left hip. The facility policy and procedure titled "FALL MANAGEMENT POLICY AND PROCEDURE. PC-168," revised 12/10, indicated "Prevention/Intervention Strategies...On skilled nursing patients, Registered nurse will implement the fall prevention interventions on the Fall Risk Assessment/Plan of Care..." Therefore, the facility violated the regulation by failing to implement Resident 1's care plan for fall precaution. This failure caused Resident 1 to sustain a left hip fracture after falling while getting up unassisted from the toilet in the bathroom and required Resident 1 to undergo a left hip surgery. The violation of the regulation had presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000976 |
SUNRISE II |
110011332 |
B |
27-Mar-15 |
I7EZ11 |
5554 |
W127 Protection of Clients Rights 483.420(a)(5) The facility must ensure the rights of all clients. Therefore, the facility must ensure that clients are not subjected to physical, verbal, sexual or psychological abuse or punishment. The facility failed to ensure the protection of Client 1's right to be free from physical and/or sexual abuse, when she was subjected to repeated fondling by a direct care staff member. Findings:Review of the clinical record revealed Client 1 was a 21-year-old female, admitted to the facility on 11/15/13, with diagnoses of profound intellectual disability and seizure disorder. Client 1 was alert, ambulatory, capable of feeding and dressing herself with supervision, and was non-verbal. Client 1 attended school every day.On 2/13/15, the Department received a Special Incident Report (SIR) dated 2/13/15, from Administrative Staff A regarding incidents that occurred on 2/12/15, and involved Client 1 and Residential Technician (RT, also known as direct care staff) B. The report indicated the following: "At 10:20 pm, [RT C] reported by phone to [Administrative Staff D] . . . that coworker [RT B] touched [Client 1's] breasts." The SIR indicated RT C initially thought he saw RT B at 4:15 p.m. on 2/12/15, with his hands down Client 1's shirt. RT C decided to use his cell phone to secretly take videos of any further incidents, and set up his phone in the dining room. RT B was captured on video at 4:30 p.m. twice fondling Client 1's breast. RT C again captured video at 5 p.m. of RT B fondling Client 1's breasts, "several times," while they were in the facility's living room. At 7:20 p.m., RT B was once again captured on video fondling Client 1. The SIR indicated RT C reported the incidents to his supervisor, Administrative Staff D, at 10:20 p.m. on 2/12/15. Administrative Staff D then immediately reported this to Administrative Staff A. RT B was, "off-shift," at that time and was not scheduled to return to the facility until 2/13/15 at 2 p.m. The SIR indicated that on 2/13/15 at 9 a.m., RT C was interviewed at the facility's main corporate office by Administrative Staff A, D, and E, at which time they all viewed the videos and then contacted the police. The police arrived at the office at approximately 9:30 a.m., interviewed RT C, and decided to come back to interview RT B at 2 p.m. at the office. RT B, scheduled to work that afternoon, was contacted by Administration and told to report to the office before he started his regular evening shift, from 2 p.m. until 10 p.m. RT B was met by the police and taken to the police station, where he was questioned. RT B was placed on administrative leave at that time. During an interview on 2/14/15 at 9:45 a.m., Administrative Staff A stated RT B had been arrested on 2/13/15, and the police investigation was on-going. Administrative Staff A stated Client 1's mother had been notified of the incident and accompanied Client 1, Administrative Staff D, and police, to an evidentiary examination to check for further physical evidence of sexual assault. Administrative Staff A stated Client 1's mother tried to talk with Client 1 (who is non-verbal) about the incident, but Client 1 did not seem to understand. During an interview on 2/17/15 at 11 a.m., Police Detective (PD) F stated RT B had been questioned for over two hours, arrested, booked, and subsequently posted bail. PD F stated police felt the videos clearly showed RT B groped Client 1's breasts multiple times, and the case had been turned over to the District Attorney. During review on 2/18/15, RT B's personnel file contained fingerprint clearance and documentation of reference checks obtained prior to his hire date of 5/20/13. The file contained documentation of abuse prevention training, attendance at annual abuse prevention training, and an annual performance evaluation dated 6/18/14, which indicated RT B was, "a fine caregiver." Documentation of annual abuse prevention training, dated 9/16/14, indicated RT C and RT B had both attended and signed the sign-in sheet.During an interview on 2/19/15 at 9:45 a.m., RT C stated he saw RT B on 2/12/15, at approximately 4:15 p.m., with his arm around Client 1's shoulders, who quickly removed his hand/arm when he realized RT C saw him. RT C stated he then saw RT B with his hand under Client 1's shirt at approximately 4:25 p.m., and decided to obtain video evidence because he was afraid no one would believe him if he reported what he saw RT B doing. RT C secretly took videos with his cell phone of RT B fondling Client 1 and stated Client 1 only looked at RT B when he fondled her and did not try to fight him or push him away. RT C stated he knew that he had to report this abuse, and called his supervisor later that evening. RT C stated he had not been suspicious of RT B before. The facility's policy and procedure titled, "Prevention of Client Abuse, Neglect and Mistreatment," dated 2/5/14, indicated the following: "[Named corporate entity] forbids clients from being subjected to physical, verbal, sexual or psychological abuse or punishment or neglect." Therefore the facility failed to protect Client 1's right to be free from physical and/or sexual abuse, when she was subjected to repeated fondling by a male direct care staff member, which was captured via video recording and presented to local law enforcement, and resulted in the arrest of the staff member. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to clients. |
| 010000076 |
Summerfield Healthcare Center |
110011361 |
B |
05-May-15 |
WOY611 |
7759 |
F223 ?483.13(b), 483(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. This Requirement is not met as evidenced by: The facility failed to ensure one of three sampled residents, (Resident 1), was free from sexual abuse when Unlicensed Staff D inappropriately touched Resident 1, which caused emotional and psychological distress for Resident 1. Review of an incident reported by the facility to the Department on 9/3/14, documented Resident 1 reported to Family Member 2 that Unlicensed Staff D inappropriately touched Resident 1 during care. Review of Resident 1's MDS (Minimum Data Set, a tool used to assess residents), dated 8/12/14, indicated Resident 1 had a BIMS (Brief Interview for Mental Status) score of 14 (13-15 indicates cognitively intact status). Resident 1 was her own decision maker. Resident 1's care plan, dated 8/7/14, documented for, "toilet use: requires supervision of staff participation to use toilet. Has occasional urinary incontinence which is baseline." The care plan indicated for Resident 1's Bathing: "Participated in bathing, able to perform much of the task, requires supervision." A Nursing Summary, dated 9/7/14, indicated Resident 1 required no physical help from staff for transfers. During an interview on 9/10/14 at 1:20 p.m., Administrative Staff A stated Unlicensed Staff D was placed on suspension after the reported incident involving Resident 1. During an interview on 9/10/14, at 2:30 p.m., Resident 1 declined to be interviewed stating that an account of the incident had been repeated 10 or 11 times and Resident 1 did not want to repeat it. Resident 1 stated repeating the story made her relive the incident. During an interview on 9/10/14, at 2:35 p.m., Unlicensed Staff B stated Resident 1 did everything for herself in regards to personal care. Review of a Psychologist Progress Note, dated 9/3/14, Psychologist C documented during the interview with Resident 1, Resident 1 reported a week or two ago during the night, Resident 1 awoke to Unlicensed Staff D sitting on her bed. Resident 1 reported Unlicensed Staff D had Resident 1's briefs and pajama bottoms pulled down and was washing her perineal (the area between the legs including female genitals) area. Resident 1 reported Unlicensed Staff D, "spread my lips (labia, female genitals) and washed me, then washed the outside." Resident 1 reported this happened for less than a minute, when Unlicensed Staff D looked at her, did not say anything and pulled up Resident 1's brief and pajamas and walked out of the room. Resident 1 reported she did not say anything because she was surprised when she woke up and did not know what to say or do. Resident 1 reported Unlicensed Staff D had previously touched her, in a way that made her uncomfortable, such as rubbing her back. During the interview with Psychologist C, Resident 1 reported she was independent for perineal care. Psychologist C documented Licensed Staff H had confirmed Resident 1's statement as accurate. Psychologist C documented Resident 1 was alert, attentive and fully oriented and Resident 1 experienced anxiety from the incident and had reported the event made her feel like she was raped. During an interview on 9/15/14, at 10:10 a.m., Family Member 2 stated Resident 1 reported when she woke up, someone had taken her Depends (adult diaper) off and had spread her legs and lips (vulva) open, with a washcloth and when Resident 1 woke up, he quickly put her legs back on the bed. Family Member 2 stated Resident 1 told her when Unlicensed Staff D would come into her room, Unlicensed Staff D would sit on the bed and put his arm around Resident 1. Family Member 2 stated Resident 1 felt scared and violated. Family Member 2 stated when watching Resident 1's body language, while Resident 1 told her the story, brought tears to her eyes. Family Member 2 stated she contacted Administrative Staff A on 9/2/14, after hearing Resident 1's account of the incident.During an interview on 9/19/14 at 3:45 p.m., Licensed Staff E stated Resident 1's care was minimal and sometimes Resident 1 was incontinent (having no control over bladder or bowel) at night. Licensed Staff E stated staff helped Resident 1 with meal set up and the resident ambulated (walked) unassisted. Record review of the police report titled, "Incident/Investigation Report", dated 9/4/14, regarding the police interview with Resident 1, Resident 1 reported she woke up in the middle of the night to find a person between her legs. Resident 1 did not have any pants or underwear on and her legs were spread apart with her feet hanging off either side of the bed. Resident 1 saw Unlicensed Staff D was on the bed between her legs and was rubbing her vagina (female body part) with a washcloth and his hands. Unlicensed Staff D separated the lips of Resident 1's vagina and had his hands and the washcloth inside her vagina and around the outside as well. Resident 1 could not recall if the the washcloth was wet. Unlicensed Staff D did not touch Resident 1 anywhere else on her body other than her vagina. Resident 1 sat up in bed, alarmed by what was occurring. As Resident 1 sat up, Unlicensed Staff D appeared to be startled and immediately left the room. Resident 1 told the police investigator there was no reason for Unlicensed Staff D to have been washing her vaginal area. Resident 1 takes care of her own personal care, including changing her own diapers and cleaning her private areas. Review of the police report titled, "Incident/Investigation Report," dated 9/11/14, regarding the police interview with Unlicensed Staff D, documented Unlicensed Staff D, after initially denying he ever wiped Resident 1's vaginal area, or that she needed that type of assistance, then admitted that he did so on multiple occasions and that he did use a washcloth to wipe Resident 1 "that time." When asked if he remembered Resident 1 waking up and being startled at what he was doing, Unlicensed Staff D said he did. The police detective informed Unlicensed Staff D Resident 1 had told the detective that Unlicensed Staff D was carefully wiping her vaginal area with the wash cloth. Unlicensed Staff D said, "that was possible." He stated he normally would wipe one side of her vaginal area then the other side. Unlicensed Staff D was asked by the detective, "if, on the three occasions we discussed, he ever documented giving Resident 1 'extensive care', he (Unlicensed Staff D) said no." According to this document, Unlicensed Staff D was arrested for sexual assault after the interview. Review of the facility document titled, "Allegation of Unusual Occurrence, Final Report," dated 10/9/14, indicated the detective verbally communicated that Unlicensed Staff D, under questioning at the police department, admitted providing pericare to Resident 1 and using a washcloth in her vaginal area. Unlicensed Staff D told the detective that he did this even though he was aware that Resident 1 did not require full care in this way. The document also indicated the facility suspended Unlicensed Staff D after the allegation and Unlicensed Staff D would be officially terminated from the facility. The facility failed to ensure one of three sampled residents, (Resident 1), was free from sexual abuse when Unlicensed Staff D inappropriately touched Resident 1, which caused emotional and psychological distress for Resident 1. This failure caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 110000233 |
Sonoma Valley Hospital D/P SNF |
110011509 |
A |
25-Aug-15 |
R2CH11 |
4725 |
F323 ?483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility violated the regulation by failing to provide adequate supervision for Resident 1 who was left alone in the bathroom. Resident 1 got up unassisted and fell. The fall resulted in a right hip fracture which required surgical repair. Resident 1 is an 82 year old admitted to the facility on 12/6/14 with diagnoses that included acute exacerbation of chronic obstuctive pulmonary disease (COPD), community acquired pneumonia, dementia, and a history of falls. During an interview on 2/4/15 at 9:30 p.m., Management Staff B stated that staff is expected to read the care plan for each resident and adhere to the care plan. Management Staff B stated that the expectation is that the Certified Nurse Assistant (CNA) follows the care plan when caring for the resident. Management Staff B stated that in the situation involving Resident 1, CNA C left the room while the resident was in the bathroom. Resident 1's room was close to the nurses station. If the CNA C was called away to help another resident, that CNA C could have gotten another staff person to remain with Resident 1 until the CNA C could return. During an interview on 1/15/15 at 1 p.m., Staff C stated that he had just come on duty, on 12/28/14 at approximately 7 p.m. when another CNA asked him to take over the care of Resident 1. Staff C stated that the other CNA had walked the resident into the bathroom with the resident using the walker. Staff C stated he went to Resident 1's bathroom to see if the resident was finished and ready to leave the bathroom. Staff C stated that Resident 1 cursed at him and told him to leave. Staff C stated that the bathroom door was left open. Staff C stated that he went to assist another resident. After he finished helping another resident, he heard noise coming from Resident 1's room. Staff C stated that by the time he got to Resident 1's room, several staff were there assisting the resident. Staff C stated that Resident 1 was on the floor near the doorway of the bathroom.During an interview on 1/15/15 at 10:30 a.m., Staff D stated that Resident 1 would indicate that she needed to go to the bathroom by attempting to get out of bed or out of the wheelchair which would cause the alarm to go off. Staff D stated that Resident 1 would not use the call bell to get assistance, but if asked if she needed to use the bathroom, she would answer. Staff D stated that Resident 1 always wanted the door to the bathroom closed but that she would leave the door open slightly and stand outside the door until the resident was finished. Staff D stated that Resident 1 would not call for assistance or use the call bell in the bathroom when she was finished. Staff D stated that on 12/28/14 at the change of shift at approximately 7:30 p.m., she assisted Resident 1 into the bathroom. Resident 1 was able to walk using her walker. Staff D stated that she signed off to Staff C about Resident 1 and left the facility. During an interview on 1/20/15 at 9:30 a.m., Licensed Nurse E stated that on 12/28/14 at the change of shift following report from the day Licensed Nurse at approximately 7:30 p.m., she started rounds. Licensed Nurse E stated that she heard a noise from Resident 1's room which was not an alarm. Licensed Nurse E stated that when she got to Resident 1's room, the resident was on the floor on her left side halfway between the bathroom and the bed. During a review of Resident 1's clinical records on 1/15/15, the entry dated 12/27/14 in the Daily Focus Assessment Report titled Safety Checks indicated the following: " Group Note: Set off bed alarm trying to get OOB( out of bed) without assistance." On the Interdisciplinary Care Plan titled Safety Fall Risk dated 12/6/14 the following items were checked: Poor safety awareness, Assist with all transfers, Do not leave patient unattended on toilet or BSC( bedside commode). The entry dated 12/27/14 titled Fall Risk Evaluation indicated the following: "Remain with patient when in the bathroom or on commode, Ambulate and Transfer with Gait Belt."Therefore, the facility violated the regulation by failing to provide adequate supervision for Resident 1 who was left alone in the bathroom. Resident 1 got up unassisted and fell. The fall resulted in a right hip fracture which required surgical repair. 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. |
| 010000060 |
Seaview Rehabilitation & Wellness Center, LP |
110011594 |
B |
09-Sep-15 |
813011 |
5157 |
1418.91 (a) Health & Safety Code 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. 1418.91 (b) Health & Safety Code 1418 (b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report an allegation of physical abuse to the Department of Public Health, State Licensing and Certification Agency in a timely manner. This failure resulted in the Department's inability to independently investigate the abuse allegation without delay, had the potential for Resident 1 and other residents to be exposed to further abuse and likely continued to cause fear and anxiety to residents who had heard about the incident and saw that the perpetrator was not removed from resident care immediately following the incident. The Department's Intake Information form, dated 1/14/15, indicated that the facility (Administrator A) reported an allegation of employee to resident abuse. The incident occurred on 1/2/15. During a review of the clinical record for Resident 1, the Face Sheet (admission record) indicated that Resident 1 was a 48 year old female, who was admitted to the facility on 12/29/14. The Minimum Data Set (MDS) (an assessment tool) Section I, dated 1/9/15, indicated multiple active diagnoses including hypertension, peripheral vascular disease or peripheral arterial disease, diabetes mellitus. Section C - Cognitive Patterns, Brief Interview for Mental Status (BIMS) indicated a summary score of 13/15 (15 denotes the resident was able to understand and is oriented to year, month and day). During an interview on 1/13/15, at 5:45 p.m., Resident 1 stated that while she was assisted with a shower by Unlicensed Staff B, he grabbed her breasts. Resident 1 stated that this had happened a few days ago. The 1/2/15 incident was reported to CDPH and to Administrator A on 1/13/15 at 6:00 p.m. During an interview on 1/14/15 at 9:15 a.m., Resident 1 stated Unlicensed Staff B was giving her a shower and he touched her breasts inappropriately.During a concurrent interview and document review on 1/14/15 at 3:00 p.m., Administrator A indicated her review of the Shower and Bath Schedule dated 12/28/14 - 1/3/15 documented Resident 1 received a shower on 1/2/15 and was assisted by Unlicensed Staff B. She further stated she did not locate documentation after 1/2/15 that Resident 1 had received assistance during a shower by Unlicensed Staff B. A written statement by Unlicensed Staff B, signed, not dated, indicated that Unlicensed Staff B assisted Resident 1 "on Jan. 2nd Friday evening ...I took the resident to the shower ..." During an interview on 1/14/15 at 2:45 p.m., Licensed Staff C stated she became aware of the incident from two residents. She stated Resident 2 told her about the incident with Resident 1 and Unlicensed Staff B. She stated she interviewed Resident 1 about the incident and at that time counseled Unlicensed Staff B. She stated she did not report Resident 1's allegations to administration at the time she became aware of the incident on 1/2/15.The facility policy and procedure titled "Reporting Abuse to Administrator," revised 1/1/12, indicated "Facility Staff, ...must promptly report any incident or suspected incident of resident neglect, abuse, mistreatment, or misappropriation of resident property to the Administrator." The facility policy an procedure titled "Reporting Abuse," revised 9/1/13, indicated "...Reporting Requirements A. The Facility will report known or suspected instances of physical abuse to the proper authorities by telephone or through a confidential Internet reporting tool as required by state and federal regulations ...If the reportable event does not result in serious bodily injury, the Administrator, or his/her designee, will make a telephone report to the local law enforcement agency within twenty-four (24) hours of the observation, knowledge, or suspicion of the physical abuse. In addition, a written report shall be made to the ...California Department of Public Health, ...within twenty-four (24) hours of the observation, knowledge, or suspicion of the physical abuse ..." The facility's follow-up investigation letter, dated 1/23/15, indicated the charge nurse (Licensed Staff C) was aware of the concerns of inappropriate touching of breasts during a shower verbalized by Resident 1.The Department's investigation identified that the facility failed to report an allegation of physical abuse to the Department of Public Health, State Licensing and Certification Agency in a timely manner. This resulted in the Department's inability to independently investigate the abuse allegation without delay. This practice had the potential for Resident 1 and other residents to be exposed to further abuse and likely continued to cause fear and anxiety to residents who had heard about the incident and saw that the perpetrator was not removed from resident care immediately following the incident. The above violations had direct relationship to the health, safety or security of the resident. |
| 010000974 |
SUNRISE I |
110011695 |
B |
20-Oct-16 |
O5TP11 |
4175 |
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 protect one client (Client 1) from harm during transportation, when Client 1's wheelchair fell backwards. This failure resulted in Client 1 sustaining a laceration on the back of the head that required eight sutures. The facility is a six-bed, Intermediate Care Facility (ICF) for the developmentally disabled. The facility is Habilitative licensed (health care services that help keep individuals learning, or improving, skills and functioning for daily living) to provide care and services to individuals with developmental disability, and intellectual disabilities. Client 1 was dependent on the facility for all basic health and safety needs. Client 1 was wheelchair dependent. Client 1 attended a day program daily, Monday through Friday, and was transferred to and from the program by a contracted local transportation company. The day program provided six hours of activities that promoted independence, learning, and socialization at every opportunity. During an interview on 5/5/15 at 3:36 p.m., Driver A stated that on the afternoon of 4/28/15, he drove Client 1 from her day program to her home. Driver A stated Client 1 fell back in her wheelchair and hit the floor as the van was, "taking off," from a stopped position, two blocks from Client 1's home. Driver A stated there was blood which required his transportation assistant, Aide B, to apply pressure with a towel to the back of Client 1's head. Driver A stated he and Aide B, were responsible for securing clients before transporting them. Driver A stated Client 1's wheelchair had not been secured prior to transporting her. A review of the hospital emergency record, dated 4/28/15 at 1733 (5:33 p.m.), indicated Client 1 suffered a scalp laceration which required sutures. During an observation on 5/5/15 at 4:09 p.m., Client 1 had eight staples at the back of her head. Client 1 stated the incident happened fast, and she had some neck pain for a couple of days after the accident. Client 1 stated her wheelchair had not been tied down and secured in the back as it should have been. An online review on 5/7/15 at 1:35 p.m., of the transportation brokerage firm's, "Mission Statement," indicated the following: "To partner with our customer to provide transportation management strategies and services that produce safe, reliable...transportation systems." During a telephone interview on 5/7/15 at 2:35 p.m., Quality Management C stated that an internal investigation, with the transportation company involved, indicated Driver A was accountable for the safety of his passengers. A review of, "Job Title: Paratransit Driver," revised 4/1/12, included the following: "Assist passengers on and off the vehicle and ensure that seat/shoulder belts and/or wheelchair belts are properly fastened and/or secured." The, "Agreement for Transportation Services," vendor # ZG9621, dated 4/1/15 through 6/30/2018, page 21, 9.12, indicated: "No vehicle shall depart from a stop until the driver has determined that all consumer seat belts and wheelchair tie-downs have been appropriately secured." Therefore, the facility failed to protect one client (Client 1) from harm during transportation, when Client 1's wheelchair fell backwards, which resulted in Client 1 sustaining a laceration on the back of the head which required eight sutures. This violation had a direct relationship to the health, safety or security of clients. |
| 630001741 |
SANTA LUCIA |
110011800 |
B |
16-Nov-15 |
1XT011 |
3631 |
483.420(a)(5) Protection of Clients Rights The facility must ensure the rights of all clients. Therefore, the facility must ensure that clients are not subjected to physical, verbal, sexual or psychological abuse or punishment.The facility failed to protect Client 1 from physical and psychological abuse or punishment when a staff member at Day Program XX removed a knife from his pants, opened the knife, then physically and verbally threatened Client 1 with bodily harm resulting in the client being traumatized and had the potential for other clients, who may have witnessed the event, to also be traumatized. The facility is a 6 bed Intermediate Care Facility for the Developmentally Disabled-Habilitative licensed to provide care and services to people with varying degrees of developmental disability. Client 1 was dependent upon the facility for basic needs. Client 1 was a non-conserved adult who had a mild to moderate intellectual disability.During an interview on 9/16/15 at 10:30 a.m., Staff C stated on 9/11/15 he, Staff A and Staff D were completing an outing with clients from Day Program XX and were preparing to return, on Day Program XX bus, back to Day Program XX. While preparing the clients, adjusting seat belts and ratcheting down wheelchairs, for the ride back to Day Program XX, Staff C stated he observed Staff A and Client 1 seated next to each other on the bus. Staff C stated Staff A was speaking to Client 1 and told her not to get into the other client's lunch boxes. At the same time that Staff A and Client 1 were talking, Staff A removed a knife from his pants exposing the blade and placing the blade onto Client 1's fingers. Staff A told Client 1 to stop getting into the lunch boxes or he (Staff A) would cut her fingers. Staff C stated he separated Staff A from Client 1 and drove back to the day program. Staff C stated upon returning to Day Program XX, Client 1 started crying and would not separate from Administrative Staff F. Staff C stated he did not call his supervisor or inform the local police at the time of the incident but did report the incident to Administrative Staff E upon return to the day program.During an interview on 9/16/15 at 11:20 a.m., Staff D stated that while she was standing, inside and at the front of the bus, she observed that Staff A and Client 1 were seated at the front of the bus on the right hand side. Staff D stated that she saw Staff A take a knife out of his pocket open the blade onto Client 1's hand and asked Client 1 to stop touching the lunch boxes. Staff D also stated Staff A was separated from Client 1 by Staff C. They all returned to Day Program XX and she and Staff C reported what had occurred on the bus to Administrative Staff E. During a record review on 9/21/15, the medical record for Client 1 was reviewed. A behavior plan for "Intrusiveness" was noted that indicated that Client 1 had a genetic condition that resulted in her being very active and having a short attention span. She received psychotropic medication to help alleviate these symptoms. If Client 1 picked up or took items that belonged to peers, staff were to verbally ask her to return the item and redirect her to her own possessions or to another task. The facility failed to ensure the right of all clients to be protected from abuse when: A staff member at the day program held an open knife onto the fingers of Client 1 and verbally threatened her resulting in Client 1 becoming threatened and fearful.The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to clients. |
| 630001741 |
SANTA LUCIA |
110011801 |
B |
16-Nov-15 |
1XT011 |
3413 |
1418.91(a) Health & Safety Code 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.1418.91(b) Health & Safety Code 1418 (b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report an allegation of employee to resident abuse to the Department within 24 hours, with the potential for ongoing abuse to Client 1 and other clients. The facility is a 6 bed Intermediate Care Facility for the Developmentally Disabled-Habilitative licensed to provide care and services to people with varying degrees of developmental disability. Client 1 was dependent upon the facility for basic needs. Client 1 was a non-conserved adult who had a mild to moderate intellectual disability.During an interview on 9/16/15 at 10 a.m., Administrative Staff B stated on 9/11/15 at 12:30 p.m., Client 1 along with six other day program clients, were on Day Program XX bus coming back to the Day Program XX after a morning outing. Client 1, after being seated on the bus and waiting for the other clients to be seated and secured in their respective seats, was noted to open a lunch box, not belonging to Client 1 but to another client on the bus. Administrative Staff B stated Staff A, who was seated next to Client 1, removed a pocket type knife from his pants, opened the knife and placed the open knife blade across the fingers of Client 1. Administrative Staff B stated Staff A then verbally threatened Client 1 with cutting Client 1's finger if she did not stop opening the other client's lunch boxes. Administrative Staff B also stated that the police were not called but stated she would call them today. During an interview on 9/16/15 at 10:30 a.m., Staff C stated he observed Staff A and Client 1 seated next to each other on Day Program XX bus. Staff C stated Staff A was speaking to Client 1 and telling her not to get into the other client's lunch boxes. At the same time Staff A and Client 1 were talking, Staff A was holding an open knife, which he placed onto the fingers of Client 1 and told Client 1 to stop getting into the lunch boxes or he (Staff A) would cut her fingers. Staff C stated he separated Staff A from Client 1 and drove back to the day program. Staff C stated he did not call his supervisor or inform the local police at the time of the incident but did report to Administrative Staff E upon the return to the day program. During a document review on 9/16/15, a policy from Facility YY, titled "Prevention of Abuse, Neglect and Mistreatment", undated, indicated that "Any incident of substantiated abuse will be reported to the Local Department of Health Services Licensing and Certification Office by telephone immediately." During an interview on 9/21/15 at 9:30 a.m., Administrative Staff G stated the police were not informed either by phone or FAX concerning the abuse incident. Administrative Staff G also stated the state licensing agency was not informed of the incident until 9/13/15, when a Special Incident Report Form was completed.The facility failed to report an allegation of employee to client abuse to the Department within 24 hours, with the potential for ongoing abuse to Client 1 and other clients.The above violations had direct relationship to the health, safety or security of the client. |
| 010000208 |
Spring Lake Village |
110011872 |
A |
18-Dec-15 |
2KNW11 |
10217 |
72311(a)(1)(B) 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. The facility failed to keep Resident 1, who was a high risk for falls, free from injury, when it failed to provide a care plan that met Resident's 1's specific needs for adequate supervision. Resident 1 sustained four documented falls, resulting in injury and hospitalization, during a five-month period, leading to her gradual decline. Resident 1 died on 7/9/13. Findings: A letter from the facility to the Department, dated 5/31/13, indicated Resident 1 was admitted to the facility on 12/29/12, with diagnoses including rehabilitation, aftercare surgery of circulatory system, circulatory disease and diabetes mellitus II. Other diagnoses include muscle weakness-general, aftercare traumatic fracture of hip, difficulty in walking, aftercare joint replacement, joint replaced hip, personal history of fall, and peripheral vascular disease. Review of Resident 1's Falls Care Plan, dated 1/4/13, indicated to encourage Resident 1 to ask for assistance/assist as needed, ensure that she had proper footwear, orient her to her room/environment, re-orient her as needed, place her call light within reach, administer medications as ordered, monitor for adverse reactions from medications, fall precautions per protocol, and rehab per MD (Medical Doctor).Review of a facility document on interventions for a resident at high risk for falls (undated), included but were not limited, to the following: Evaluate for pain.....toileting needs, as indicated. Reduce environmental stressors and provide calm/quiet environment. Provide activities as appropriate. Tab alarms (pressure or tab) may be used depending on the resident's mobility and cognition. Fall mats could be used if continued attempts to exit a bed were noted. Ultra-low beds could also be used unless it was determined that the bed would increase the risk of falls. 1:1 caregiver may be used if all other interventions failed. All interventions would be reviewed as soon as able, by the IDT, for appropriateness and adjusted as needed.Review of Resident 1's Activities of Daily Living (ADL) Care Plan, dated 3/11/13, indicated Resident 1 required extensive assist with toileting use, personal hygiene, transfers, walking, dressing, bathing, and that staff would meet ADL's. A notation on Resident 1's Fall Care Plan, of 3/11/13, indicated Resident 1 had impaired mobility with need for extensive assist for transfers and ambulation....."Recent partial hallus amputation rt. ft. (right foot)."On the Tinetti Assessment (test for balance and gait), dated 4/8/13, Resident 1 had a score of 16/28, indicating high risk for falls. Resident 1's Minimum Data Set (MDS, an assessment tool), dated 5/6/13, indicated Resident 1 was alert and oriented, with a cognitive score of 15. A score of 13-15 suggests being cognitively intact.Fall #1 On 01/09/13, while Resident 1 was walking with the Physical Therapist, Resident 1 tripped on a cord and incurred a left femoral neck fracture, was hospitalized, and treated with hemiarthroplasty (an operation that is used most commonly to treat a fractured hip).Interventions added to Resident 1's 3/11/13, Fall Care Plan, on 4/18/13, included RNA (Restorative Nursing Assistance) for exercise and ambulation......"Respect Resident 1's wish for indep. (independence) while encouraging/reminding her to ask for assist [with] transfers and amb. (ambulation)."Fall #2 Nurses Notes, dated 5/30/13, indicated while Resident 1 was being toileted, Resident 1 fell, complained of right hip pain and was unable to move. Resident 1 was sent out to the hospital for evaluation and to rule out a right hip fracture. During a telephone interview on 6/5/13 at 4:44 p.m., Unlicensed Staff C stated that on 5/30/13 at about 1:45 a.m., Unlicensed Staff C assisted Resident 1 to the bathroom, using a walker, opened the bathroom door for Resident 1, left the door partly closed, walked out and heard Resident 1 fall. The hospital Discharge Diagnosis, dated 6/6/13, indicated Resident 1 had a fall resulting in a comminuted right hip fracture requiring surgery. Resident 1's Discharge Summary, dated 6/6/13, from the acute care hospital, indicated that Resident 1 was close to becoming only comfort care as she did not appear to be recovering from any of the procedures she endured, and she continued to dwindle down and was now becoming cognitively impaired. On 6/6/13, after a facility readmission assessment, Resident 1's fall risk score was 65, and on 6/23/13, her fall risk score was 90. An MFS score greater than 50 was high risk. Action required was to initiate High Risk Fall Prevention Interventions for high risk.During a telephone interview on 6/6/13 at 3:05 p.m., Management Staff A stated Resident 1 returned from the hospital to the facility on the morning of 6/6/13....."cognitively intact but the incident [fall requiring surgery] have [sic] worn her down." During a telephone interview on 6/13/14 at 3:35 p.m. Management Staff A stated, "We have no standard list for fall prevention. We might initiate a low bed, foam mat next to the bed, sometimes 1:1 [supervision], for dementia residents a dementia resident program. We look at toileting, what puts them at risk." During an interview on 10/28/14 at 11:35 a.m., when asked if it was okay for staff to leave a resident alone in the toilet, if the resident was an extensive assist with ADLs like toileting use, personal hygiene, transfers, walking and dressing, Management Staff E stated, "Not typically to leave alone." During a telephone interview on 5/8/15 at 11 a.m., Rehab Director G stated extensive assist was typically maximum assist but if the, "patient is with profound weakness and instability can't be left alone behind a door because of fall risk." Falls #3 & #4 During observation on 7/5/13 at 4:42 p.m., Resident 1 was in bed and not responsive.Review of Nurses Notes, dated 6/23/13, documented two more falls at 4:50 p.m. and 9:50 p.m. Resident 1 had a witnessed fall at 4:50 p.m., after medication administration with Norco (a narcotic pain medication used for moderate to severe pain, ordered on 6/6/13, as indicated on June 2013's Physician Order Sheet) at 3:25 p.m. Common side effects after Norco administration were dizziness and light headedness. Resident 1 was seen standing, took a few steps, then fell near the door frame. Resident 1 had a sitter until 8 p.m. After the sitter went home, Resident 1 was toileted and put to bed in a low position and an alarm in place. Resident 1 remained awake and was asking when she was going home. At 9:50 p.m., the alarm was sounding again, and Resident 1 was found on the floor, on her right side.Record review of Resident 1's chart also revealed a care plan, dated 6/13/13, for anxiety. The care plan indicated to provide 1:1 staff as a safety measure prn [as needed] during increased episodes of agitation....."Res. [Resident] presents danger to self, i.e. [that is] attempting to stand unassisted." Review of a document titled, "Sitters in Place for [Resident 1's Name]," showed a schedule of sitters and sitter contact information. Between 6/11/13 and 6/30/13, a sitter was scheduled around-the-clock for 15 of the 19 days. On 6/22/13, no sitter was scheduled, and on 6/23/13, the day of Resident 1's two falls, a sitter was scheduled for three and one-half hours. The sitter's shift was scheduled to start approximately forty minutes after Resident 1's second fall of that day.Review of physician telephone order, dated 6/17/13, indicated, "comfort care."Review of Nurses Notes, dated 6/21/13, 6/22/13, and 6/23/13, documented that Resident 1 had episodes of confusion, forgetfulness, anxiousness, complaints of pain, and calling out. During an interview on 7/5/13 at 5:25 p.m. for the witnessed fall on 6/23/13 at 4:50 p.m., Licensed Staff B stated Resident 1 was seated on a wheelchair with her legs on the leg rests; she removed the pillows, got up between the leg rests, and walked about six feet really fast and allowed self to slump on the doorway, skidding to the floor. During an interview on 7/5/13 at 6:43 p.m. Unlicensed Staff I stated, Resident 1, "was not the same after her cognition declined coming back from the hospital." On 10/22/14 at 1:42 p.m., during a telephone interview with Licensed Staff D, when asked for narcotic pain medication side effects stated, "Sedation, hallucination, bowel problems and decreased blood pressure." When asked what were the reasons a resident would be on a 1:1 sitter, Licensed Nurse D stated to watch out for side effects of narcotic administration, for unsafe behavior, for getting out of bed, if a resident had no safety awareness or a change in mentation, or if a resident did not know how to call for help. During a telephone interview on 10/22/14 at 2:15 p.m., when asked if the fall triggered Resident 1's decline, Physician F stated Resident 1 had other medical problems of peripheral vascular disease, hypertension, hyperlipidemia, diabetes, anemia among others but, "the fall set up her decline. I believe so."During a telephone interview on 10/28/14 at 2:38 p.m., Management Staff E stated no sitter was scheduled on Saturday, 6/22/13 nor on Sunday, 6/23/13, because Resident 1 was calmer, and her bed was lowered. (A facility Visitor Log for 6/23/13, included a notation by Management Staff E, which indicated that Resident 1's, "sitter" that day, was actually her DPOA, who visited Resident 1 between Fall #1 and Fall #2 on 6/23/13). Therefore, the facility failed to keep Resident 1, who was a high risk for falls, free from injury, when it failed to provide a care plan that met Resident's 1's specific needs for adequate 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. |
| 010000060 |
Seaview Rehabilitation & Wellness Center, LP |
110011899 |
B |
05-Apr-16 |
KNNB11 |
3147 |
1418.91(a) Health & Safety Code 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. 1418.91(b) Health & Safety Code 1418 (b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed report an incident of resident to resident abuse to the Department of Public Health within 24 hours when Resident 1 struck Resident 17 on his right knee with a closed fist on 10/3/15. This failure resulted in the Department's inability to independently investigate the physical altercation without delay. This failure had the potential for other residents to be exposed to physical altercations with Resident 1 or Resident 17 if measures were not taken to ensure a complete investigation, implementation of effective interventions, monitoring and a follow-up investigation. During an interview on 12/11/15 at 11:30 a.m., the facility administrator (Administrator A) stated that Administrator L was at the facility at the time that the altercation occurred.During a phone interview on 12/11/15 at 11:40 a.m., the administrator (Administrator L) who was in charge at the time of the altercation between Resident 1 and Random Resident 17, stated that he thought Random Resident 17 and Resident 1, were engaged in a shouting match and slapped each other before they were separated. Administrator L stated that he did not know if the incident was reported to the State Agency.During an interview on 12/11/15 at 12 p.m., the Assistant DON (Director of Nurses) stated, one Resident hit the other resident on the knee. The Assistant DON stated that it was reported to her on 10/3/15 and the administrator as well.Review of the facilities copy of two Confidential Reports submitted to long term Ombudsman on 10/5/15 indicated that there was altercations between Resident 1 and Random Resident 17 on 10/3/15 where Resident 1 struck Random Resident 17 on the knee. Both forms indicated that each resident was the victim of abuse as well as the abuser. The form did not indicate that the altercation was reported to California Department of Public Health. A review of a policy dated 1/1/12, tilled "Reporting Abuse to State Agencies and other Entities" indicated in order to ensure compliance with laws and regulations regarding reporting of incidents and suspected incidents of abuse, neglect and mistreatment of residents and also indicated that the facility does not condone any form of resident abuse, neglect or mistreatment, and promptly informs/notifies the following persons or agencies orally or in writing of the report. Under procedure, the Administrator or designee will make required reports upon notification of a suspected or substantiated incident of mistreatment, neglect, injuries of an unknown source or abuse (including resident to resident abuse) to the appropriate authorities including the State Department of Public Health. Therefore, the facility failed to notify the Department within 24 hours of an alleged incident of abuse resulting in an automatic B violation. |
| 010000060 |
Seaview Rehabilitation & Wellness Center, LP |
110012467 |
A |
16-Aug-16 |
95ZV11 |
9273 |
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 1 the necessary care and services for the prevention of an avoidable pressure ulcer when the facility failed to implement strategies that minimize the risk for pressure ulcer development and not identifying the use of pressure-redistributing equipment in the care planning of Resident 1's identified risk for developing pressure ulcers. These failures resulted in harm to Resident 1 when he developed a stage 4 pressure ulcer (full thickness skin loss with extensive destruction, tissue necrosis (the death of tissue or damage to muscle, bone or supporting structures due to disease, injury, or failure of the blood supply). The pressure ulcer became infected and the infection spread to Resident 1's blood stream (sepsis). The results of the facility's failures caused Resident 1 pain, presented the potential for death, and required hospitalization, prolonged intravenous antibiotic therapy and surgical interventions to treat the infected pressure ulcer. Findings: Resident 1 was admitted from an acute hospital for aortic valve replacement (aortic valve replacement is a procedure in which a patient's failing aortic valve is replaced with an artificial heart valve) to the facility, a full code (it is a hospital designation referring to the level of medical interventions a patient wishes to have started if the heart or breathing stops) on 11/18/15, with diagnoses that included abnormalities of gait and mobility, aortic stenosis,(Blood from the heart is pumped through the aortic valve. A narrow aortic valve limits the circulation of oxygenated blood to the rest of your body), diabetes mellitus (a medical condition in which sugar levels can build up in your bloodstream), delirium (a severe disturbed state of mind that occurs in fever, intoxication, and characterized by restlessness, delusions, and incoherence of thought and speech). Review of Resident 1's acute hospital Transfer Summary, dated 11/18/15, under "Skin Condition," indicated no pressure areas/ulcers. Review of Resident 1's Admission Assessment, dated 11/18/15, indicated Resident 1's skin was pink, dry/flaking, fair in turgor (the degree of elasticity of skin) and warm. No pressure ulcer was identified. Review of the Braden Scale for predicting Pressure Sore Risk dated 11/19/15, indicated Resident 1 scored 13 indicating moderate risk (total score less than 9 indicate severe risk). With regard to long term care ( LTC) residents, calculating a Braden Scale score on admission, every week for 4 weeks, and then again either monthly or quarterly is suggested. (References: National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer stages/categories). Review of the MDS (Minimum Data Set, a Resident assessment tool), dated 11/25/15, indicated Resident 1 had a cognitive score of 0 indicating severe impairment (0-7 severe impairment; 13-15 cognitively intact; 8-12 moderately impaired), had short and long-term memory problems, needed extensive assistance of one person physical assist for bed mobility, transfers, dressing, and toileting. Additionally, the MDS indicated Resident 1 was always incontinent of bladder and bowel, had a nutritional risk and was at risk of developing pressure ulcers. Review of Resident 1's "Care Plan Incontinence," dated 11/19/15, indicated interventions, among others, to provide incontinence care after each incontinent episode and to observe skin for any abnormalities during toileting and/or changing. During an interview on 12/30/15 at 9 a.m., Unlicensed Staff A, working a morning shift on 12/2/15, stated he observed an open area without a dressing on Resident 1's right buttock. Unlicensed Staff A reported to License Nurse E. During an interview on 12/30/15 at 10:55 a.m., the DON stated Resident 1 was at a high risk for developing skin breakdown due to Resident 1's diagnoses of diabetes mellitus, Wernicke's encepalopathy (a serious neurologic disorder from Thiamine (vitamin B-1) deficiency), and delirium (Delirium is a serious disturbance in mental abilities that results in confused thinking starting in hours or a few days). During an interview on 12/30/15 at 12:02 p.m., when asked how Resident 1 spent his day Licensed Staff B stated, "He spends most of his day in the wheelchair and is taken back to bed after lunch. The evening staff would get him up and take him back to bed after dinner." Residents may experience more rapid skin breakdown while sitting for prolonged periods in a chair, as the ability to distribute pressure over the pelvis is more limited than when they are lying in a bed. (References: National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer stages/categories). Review of Resident 1's " Care Plan Skin" dated 11/18/15, did not include pressure redistributing devices for chair and bed (provides alternating pressure and is designed to be used in the prevention, treatment and management of pressure ulcers), indicated to turn and reposition, monitor for signs and symptoms of infection." During a telephone interview on 2/16/16 at 4:50 p.m., Licensed Staff C, working on an evening shift, stated he first knew of Resident 1's open area on the buttock on 12/5/15. When asked what he saw, Licensed Staff C stated, "I saw a sore on Resident 1's bottom. It looked like a popped blister; it was without skin (looking raw without the protective skin covering)." Licensed Staff C also stated he did not measure and document the open area but passed on the information to the night nurse. Review of Nurse's Notes, dated 12/5/15 at 12:30 p.m., indicated Resident 1 did not get out of bed for lunch, still feeling drowsy, increased jerking in hands and arms and felt warm to touch. Resident 1's axillary (underarm) temperature was 99.1 (Normal body temperature is considered to be 98.6 F). Nurse's Note entry 12/6/15, a.m., indicated temperature 101. On 12/7/15 at 11:50 a.m., increased tremors were noted, and Resident 1's temperature was 102. Resident 1 required hospitalization on 12/08/16, for evaluation and treatment. Review of the acute hospital's Admission Report dated 12/9/15 indicated Resident 1 being febrile (temperature of 101.8) and increasingly altered level of consciousness and a right buttock decubitus (a pressure ulcer, pressure sore, or bed sore, is an open wound on the skin) into the fascia (a thin sheath of fibrous tissue enclosing a muscle or organ). Review of the acute hospital's Progress Note, dated 12/10/15, indicated a right coccyx (tailbone)/sacrum (a large, triangular bone at the base of the spine)/ischial (as a pair the sitting bones) ulcer with periulcer erythema (surrounding redness of the wound) measuring 6.52 cm (centimeter is a unit of length in the metric system,1 inch =2.54 cm) in diameter (width) and 6.14 cm in length, 100% non-viable (dead tissue) wound bed, requiring excisional debridement (the surgical removal or cutting away of necrotic or devitalized tissue. Healing time: Anywhere from three months to two years.) of necrotic tissue (dead tissue, which usually results from an inadequate local blood supply). Review of the acute hospital Discharge Summary, dated 1/21/16, indicated discharge diagnoses: Sacral decubitus stage 4 (the wound extends into the muscle and can extend as far down as the bone) and Sepsis with MRSA. Blood culture and wound culture were both positive for MRSA, on admission, as indicated on the Hospitalist Progress Note, dated 1/13/16 at 1315 (1:15 p.m.). Review of facility document titled, "Skin and Wound Management," indicated under Policy: "Facility Staff will take appropriate measures to prevent and reduce the likelihood that residents will develop pressure ulcers and other skin conditions. All Nursing Staff is responsible for the prompt reporting of any sin related conditions to the Licensed Nurse. The License Nurse will notify the Attending Physician promptly at the first occurrence of a pressure ulcer or other skin related problems." Under Procedure 11. Skin and Wound Management: A. A Licensed Nurse will complete the Weekly Skin Evaluation (SK-04 -Form C- Weekly Skin Evaluation) for each resident...B. CNAs (certified nurse assistants) will complete body checks on resident's shower days and report unusual findings to the Licensed Nurse. Therefore, the facility failed to provide the necessary care and services to prevent an avoidable Stage 4 pressure ulcer, by withholding interventions that could have prevented the formation of the pressure ulcer which became infected with multiple bacterial and fungal, life-threatening organisms which resulted in pain and sepsis which required hospitalization, surgery and prolonged antibiotic treatments. This presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 010000060 |
Seaview Rehabilitation & Wellness Center, LP |
110012472 |
A |
16-Aug-16 |
95ZV11 |
7376 |
F157 ?483.10(b)(11) Notify of Change (injury/decline/room, Etc.) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in ?483.12(a). The facility must also promptly notify the resident and, if known, the 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. 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 immediately notify the physician and the responsible party of Resident 1's change in condition when: 1) Resident 1's open area on the buttock was discovered and reported to a licensed nurse; and 2) Resident 1 developed a pressure ulcer and fever for three days before the physician was notified. These failures resulted in harm to Resident 1, when he did not receive the necessary care and services to alleviate a worsening condition of a pressure ulcer which led to sepsis (Sepsis is a life-threatening condition that arises when the body's response to infection injures its own tissues and organs. Common signs and symptoms include fever, increased heart rate, increased breathing rate, and confusion). Resident 1 was subjected to unnecessary pain, required hospitalization, prolonged intravenous antibiotic therapy and surgical interventions to treat the sepsis and the infected pressure ulcer. Findings: Resident 1 was admitted from an acute hospital for aortic valve replacement (aortic valve replacement is a procedure in which a patient's failing aortic valve is replaced with an artificial heart valve) to the facility, a full code (a hospital designation referring to the level of medical interventions a patient wishes to have started if the heart or breathing stops) on 11/18/15, with diagnoses that included abnormalities of gait and mobility, aortic stenosis (is narrowing of the aortic valve). Blood from the heart is pumped through the aortic valve. A narrow aortic valve limits the circulation of oxygenated blood to the rest of your body), diabetes mellitus (a medical condition in which sugar levels can build up in your bloodstream), delirium (a severe disturbed state of mind that occurs in fever, intoxication, and characterized by restlessness, delusions, and incoherence of thought and speech). Review of the Resident Admission Assessment, dated 11/18/15, indicated Resident 1's skin was pink, dry/flaking, fair in turgor (the degree of elasticity of skin) and warm. No pressure ulcer was identified. During a telephone interview on 12/23/15 at 10:55 a.m., Family Member F stated she visited every day and that is how she knew Resident 1 was running a fever on 12/5/15, 12/6/15, 12/7/15 and 12/8/15. Family Member F also stated she was not aware Resident 1 developed a pressure sore on his buttock. During an interview on 12/30/15 at 9 a.m., Unlicensed Staff A working a morning shift on 12/2/15, stated he observed an open area, without a dressing, on Resident 1's right buttock. Unlicensed Staff A reported to Licensed Nurse E, and the wound was dressed. During a telephone interview on 2/16/16 at 4:50 p.m., Licensed Staff C stated he first knew of Resident 1's open area on the buttock on 12/5/15. When asked what he saw, Licensed Staff C stated, "I saw a sore on Resident 1's bottom. It looked like a popped blister, it was without skin" (looking raw without the protective skin covering). Licensed Staff C also stated he did not measure and document the open area but passed on the information to the night nurse. Review of Nurse's Notes, dated 12/5/15 at 12:30 p.m., indicated Resident 1 did not get out of bed for lunch, still feeling drowsy, increased jerking in hands and arms and felt warm to touch. Resident 1's axillary (underarm) temperature was 99.1 degrees F. (Normal body temperature is considered to be 98.6 degrees F. An armpit (axillary) temperature is usually 0.5øF (0.3øC) to 1øF (0.6øC) lower than an oral temperature). Review of Nurse's Note, dated 12/6/15, a.m., indicated a temperature of 101 degrees F. On 12/7/15 at 11:50 a.m., increased tremors were noted, and Resident 1's temperature was 102 degrees F. Physician D was notified three days (Nurse's Notes 12/5, 12/6 and 12/7) after Resident 1 developed his fever, with order for Tylenol, to continue monitoring and call the physician for increased tremors. During a telephone interview on 2/16/16 at 3:14 p.m., Licensed Staff E stated she initiated the SBAR (situation, background, assessment and request) notification to Physician D on 12/7/15, but addressed only the elevated temperature and Resident 1's hand tremors and not the open area on the right buttock. During an interview on 12/30/15 at 9:38 a.m., when asked when change of condition documentation for Resident 1 should have started, Licensed Staff H stated,"It should have been on the 12/5/15 a.m./p.m. shift." Review of telephone order, dated 12/8/15, by Physician E indicated, "Send to ER (emergency room) for evaluation/treatment r/t (related to) possible Septic." Review of the acute hospital Discharge Summary, dated 1/21/16, indicated Resident 1 had discharge diagnoses: Sacral decubitus stage 4 (the wound extends into the muscle and can extend as far down as the bone) and Sepsis with MRSA. Blood culture and wound culture were both positive for MRSA on admission as indicated on the Hospitalist Progress Note dated 1/13/16 at 1315 (1:15 p.m.). Review of facility document titled, "Change of Condition Notification," indicated under Procedure II: "The Licensed Nurse will assess the change of condition and determine what nursing interventions are appropriate. A. Before notifying the Attending Physician, the Licensed Nurse must observe and assess the overall condition utilizing a physical assessment and chart review. i. Notification to the Attending Physician will include 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." Therefore, the facility withheld the necessary care and services when Resident 1 experienced changes in condition and the physician was not notified in a timely manner of the open wound and fever resulting in sepsis with life-threatening organisms which required hospitalization, surgery and prolonged antibiotic treatments. This presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 010000060 |
Seaview Rehabilitation & Wellness Center, LP |
110012744 |
A |
28-Dec-16 |
LSI111 |
12027 |
F323 ?483.25(h)- Free of Accident Hazards/supervision/devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide adequate supervision for one resident (Resident 1) and ensure her environment was free of accident hazards when she fell while one staff member, instead of the required two staff, attempted to transfer her using a Hoyer lift (patient lift that utilizes a sling to transfer residents). Resident 1 had a history of generalized weakness and significant muscle spasms and was dependent on staff for all of her care needs, including movement/transport. This failure caused Resident 1 to sustain multiple rib fractures, a hemothorax (blood accumulation in the space between the chest wall and the lung which can interfere with normal breathing; most common cause is chest trauma) and a skin tear. Resident 1's injuries caused her to have increased pain and to experience fear when she was subsequently moved with the Hoyer lift. Review of Resident 1's facility face sheet (medical information), dated 8/31/16, indicated Resident 1 was a fifty-seven year old female who was admitted into the facility on xxxxxxx. Resident 1's medical record indicated she had diagnoses including multiple sclerosis, generalized muscle weakness, and difficulty walking. Her physician progress note, electronically signed 9/7/16 at 6:54 a.m., revealed she had a history of significant muscle spasms. Review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 8/16/16 (ten days before her fall) revealed she was totally dependent on staff support for transferring and she required two staff for physical assistance with transferring. Review of her MDS dated 5/16/16 (three months before her fall from the lift) indicated Resident 1 was unsteady, had impaired balance during transfers, and had a recent fall at the facility. Review of Resident 1's MDS's dated 5/16/16 and 8/16/16 (prior to her fall) revealed she had no pain. Review of Resident 1's medical record document of monthly vital signs, weights, and pain assessment indicated Resident 1 had no pain from January, 2016 through August 3, 2016. Review of Resident 1's Medication Record Administration (MAR) indicated she had no pain from August 1 through August 26, 2016 but was given Norco (narcotic pain reliever) for generalized discomfort. Review of Resident 1's nursing care plan (direction for the nursing care an individual may need) dated 8/26/16 indicated Resident 1 fell to the floor while being transferred by staff and complained of pain to her right arm and right elbow. The care plan indicated Resident 1 would be sent to a local hospital emergency room for a post fall evaluation. Review of Resident 1's SBAR notes (facility document where nurses document the situation, background, appearance and review/notification of an incident), dated 8/26/16, revealed Resident 1 had fallen and had sustained a right arm skin tear and complained of increased pain in her right shoulder and elbow. The document indicated Resident 1's pain was 7 out of 10 (pain assessment score where 1 was no pain and 10 was worst pain imaginable) and she grimaced when her right arm and shoulder were touched. The document indicated Resident 1 was sent to the local hospital's emergency room for evaluation of possible right arm fracture. Review of the Emergency Department Report dated 8/26/16 at 9:24 p.m. (documented by Physician K) indicated Resident 1's chief complaint was "right elbow pain after fall." Review of the History & Physical Report, documented by Physician G (dated 8/27/16, no time) indicated the reason for Resident 1's hospital admission was "fall." Physician G documented that Resident 1 "was being transported" in some type of lift mechanism and she fell. Physician G indicated Resident 1 was "taken in for further evaluation." Review of hospital radiology (x-ray imaging) report dated 8/26/16 at 8:26 p.m. indicated Resident 1 had a chest x-ray from one view (XR Chest 1V). The report indicated Resident 1 was "status post fall" and had fractures of the right fifth through eighth ribs. Under subtitle "Impression," the report revealed Resident 1 had "multiple right rib fractures with associated minor right hemothorax..." The report was electronically signed by Physician H on 8/27/16 at 4:58 p.m. Review of Resident 1's hospital physician progress note dated 8/29/16 at 12:39 p.m. indicated Resident 1's imaging studies had been negative regarding her fall and fractures. The physician progress note was electronically signed by Physician J on 8/31/16 at 3:30 p.m. Review of Resident 1's medical record nurse's notes revealed she was transferred back to the facility via ambulance on 8/30/16. Review of an Interdisciplinary Team (IDT) conference record dated 8/31/16 indicated Resident 1 was status post fall and required pain management. An IDT conference record dated 9/1/16 indicated Resident 1 had fractures to her right fifth through eighth ribs, as noted on x-ray report from the hospital. The report indicated the facility notified Physician I of the x-ray results. During an observation on 8/31/16 at 2:05 p.m., Resident 1 was lying in her bed. During an interview at 2:10 p.m., Resident 1 had difficulty expressing herself verbally and nodded or shook her head in response to questions. When asked if she had fallen recently, Resident 1 nodded her head up and down, indicating yes. When asked where she fell, Resident 1 used her left hand to point to her right shoulder. After that movement, she made a facial grimace. When asked if she was in pain, Resident 1 nodded her head up and down, indicating yes. When asked if she had pain before she had fallen, she shook her head side to side, indicating no. When asked if she had pain after she fell, she nodded yes. At that time, she moved slightly and again grimaced. When asked if she wanted pain medicine from the nurse, she shook her head to indicate no. During an interview on 8/31/16 at 2:25 p.m., Licensed Nurse B stated Resident 1 was alert and oriented (aware of person, place and time; not disoriented) but had problems with speech. He stated she was able to tell you "yes" and "no" and was able to answer well that way. He stated he had medicated her for pain earlier that day. When asked how her pain compared to her pain before her fall, he stated normally she went to the dining room to eat her meals but she wanted to stay in bed that day, which was unusual for her. He stated she usually smiled more but she was not smiling that day. During an interview on 8/31/16 at 2:45 p.m., Certified Nursing Assistant C (CNA C) stated she had worked with Resident 1 approximately two weeks earlier. She stated Resident 1 required maximum assistance from staff but had gotten up for breakfast and lunch at that time. When asked if she had pain when she got her up two weeks ago, CNA C stated Resident 1 was, "perfectly fine" and had not had pain. CNA C stated she had fed Resident 1 that morning (8/31/16) in bed because she had not gotten up. She stated Resident 1 was in pain during breakfast and the elevated head of the bed had caused Resident 1 pain. During an interview on 8/31/16 at 3:00 p.m., CNA D stated he knew Resident 1 and had taken care of her in the past. He stated it was hard to communicate with her but she could say "water" and "light" and was able to shake her head to indicate "yes" and "no." CNA D stated Resident 1 required maximum assistance from staff and they used a Hoyer lift to move her. He stated two staff moved her in the Hoyer lift. He stated Resident 1 got up in the wheel chair for all meals but she was now in pain and did not want to get up. During an interview on 8/31/16 at 3:20 p.m., Licensed Nurse E stated she was Resident 1's nurse the evening she fell from the Hoyer lift and she had gotten a stat (respond immediately) call to her room. She stated Resident 1 was lying on the floor, had a skin tear, and had complained of pain on her right side. She stated Resident 1 used her fingers to communicate that her pain was 7 out of 10 (on the pain scale). She stated CNA F was alone (no other staff were present) and he told her the Hoyer lift dropped Resident 1. She stated CNA F had gotten Resident 1 up in the Hoyer by himself. She stated CNA F was sent home after the incident (he did not finish working his shift). During an interview on 8/31/16 at 1:30 p.m., the Director of Nursing stated Resident 1 fell while CNA F was transferring her using a Hoyer lift. She stated Resident 1 had been injured and she had right shoulder pain and a skin tear. During an interview with Administrator A and the Director of Nursing (DON) on 8/31/16 at 3:45 p.m., Administrator A stated the root cause of Resident 1's fall was the CNA had not followed facility policy and procedure. She stated two staff members, not one, were required to transfer residents using a Hoyer lift. She stated facility maintenance staff had assessed the Hoyer's sling after the incident. She stated the sling was "okay" but it had not been hooked right. Review of Resident 1's nurse's note dated 8/31/16 at 2:50 p.m. (after she returned from the hospital) indicated Resident 1 was given Norco (narcotic pain reliever) for "moaning and groaning." Review of Resident 1's Medication Administration Record (MAR) indicated she received additional Norco later that day for "moaning/groaning." Review of Resident 1's night shift nurse's note dated 9/1/16 indicated she was given Oxycodone (narcotic pain reliever stronger that Norco) for, "severe pain, a lot of facial expressions..." and for hands clutching and tightening up. Review of Resident 1's nurse's note dated 9/3/16 at 10:25 a.m. indicated Resident 1 complained of right sided chest pain and staff gave her Norco for pain relief. The note further indicated Resident 1 was "very guarded while in Hoyer sling." A nurse's note dated 9/4/16 at 11:10 a.m. indicated Resident 1 complained of right arm/shoulder and right side chest pain and staff gave her Norco with good results. The note further indicated Resident 1 was "still afraid of using lift" to get in and out of bed. During a telephone interview and concurrent record review on 10/4/16 at 10:20 a.m., Physician I (Resident 1's primary physician) stated she was Resident 1's doctor. She stated Resident 1 was totally dependent on staff for her care and only one CNA was assisting her at the time she fell from the Hoyer lift. When asked if Resident 1's radiology results, dated 8/26/16, (that indicated Resident 1 had multiple right rib fractures with a right hemothorax) was caused from her fall from the Hoyer lift, Physician I responded, "yes." She stated that Physician J's progress note, dated 8/29/16 at 12:39 p.m., (that indicated Resident 1 had not sustained rib fractures) was not correct. Review of facility policy titled "Total Mechanical Lift" (revised 1/1/12) indicated a mechanical lift would be used appropriately to facilitate transfers of residents. The policy indicated "II. At least two people are present while resident is being transferred with the mechanical lift." Therefore, the facility failed to provide adequate supervision for Resident 1 and ensure her environment was free of accident hazards when she fell while one staff member, instead of two staff, attempted to transfer her using a Hoyer lift. Resident 1 had a history of generalized muscle weakness, muscle spasms, and was totally dependent of staff for all care needs and the facility failed to ensure she received care in a manner designed to meet her individual needs. These failures resulted in Resident 1's multiple rib fractures, hemothorax, and skin tear and caused her to experience increased pain and fear. The regulatory violation described presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 120001442 |
SIERRA VALLEY REHABILITATION CENTER |
120009044 |
A |
18-Jul-13 |
DS0U11 |
5002 |
F 325483.25(i) Nutrition Based on a resident's comprehensive assessment, the facility must ensure that a resident- 483.25(i) (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and 483.25(i) (2) Receives a therapeutic diet when there is a nutritional problem. On October 3, 2011 at 2:50 PM, an unannounced visit was made to investigate an allegation a patient lost 17 pounds in less than one month without appropriate interventions by the facility.Based on interview and record review, the facility failed to ensure one resident (Resident A) maintained acceptable parameters of nutrition.1) The facility failed to timely notify the physician of Resident A's poor meal intake and the decline of meal intake.2) The facility nurses failed to accurately identify Resident A's meal intake for several weeks.3) The facility failed to monitor weekly the percentage of nutritional supplement consumed. During an interview with the family member of Resident A on 9/29/11, at 8:35 AM, she stated, her sister (Resident A) was admitted to the facility for rehabilitation after she sustained a stroke (when the blood flow to part of the brain is interrupted or severely reduced, depriving the brain of oxygen and food. Within minutes brain cells begin to die). She was admitted to the facility at the end of 6/11 and died on 9/2/11. The month before her death, the resident lost 17 pounds (lbs.).The clinical record for Resident A was reviewed on 10/3/11, at 3:30 PM. The resident was admitted for rehabilitation secondary to a sustained CVA [(Cerebrovascular Accident) another term used for a stroke) with late effect hemiplegia (paralysis affecting one side of the body). A review of the resident's meal intake was conducted. For the month of 7/11 the resident's average meal consumption was between 40-50%. This average intake was reduced in 8/11 to an average meal consumption of 25%. On 8/11, 8/12, 8/13, 8/16, 8/17, 8/19, 8/20, 8/21, 8/22, 8/23, 8/24, 8/25, 8/26, 8/27, 8/28, 8/30, and 8/31 the resident consumed 0 % for at least one meal per day. There was no documented evidence the physician was notified when the resident's average meal consumption was 25% or when the resident began frequently refusing meals. The physician was not notified until 8/28/11 at 3:40 PM, the nurse documented, "Resident lost 17 lbs for a month; weighed 119 lbs + today, 102 lbs...Encouraged to (increase) intake of food." At 8:10 PM the nurse documented, "Faxed Dr. (X) to notify residents (sic) weight loss, (decrease) appetite + faxed physicians (sic) orders for review. Will follow-up. Endorsed." The weekly nursing notes were reviewed. On the weekly nursing summary form, there was an area titled, "Oral/Nutritional Status Review This Week". In this area, the nurse was expected to document the average meal intake for each meal; this was documented as "Good", "Fair", or "Poor". Good indicated the average meal percentage was greater than or equal to 75%. Fair indicated the average meal percentage was greater than 50% but less than 75%. Poor indicated the average meal percentage was less than or equal to 50%. For the month of 7/11, the nurses documented the resident's meal percentage as "Good" which indicated the resident was consuming greater than 75% of her meal, although the resident was consistently consuming on average less than 50% of her meal which would be considered "Poor". During the first week of 8/11 the average meal percentage was less than 50%. During the second, third and fourth weeks of 8/11 the average meal percentage was 25% with many meal refusals. In 8/11 the nurses documented week after week the resident was consuming 75% of her meal.There was also no indication how much of the liquid supplement the resident consumed, although this was also an area to be completed on the weekly nursing summary. The resident's physician had ordered a liquid nutritional supplement to be given with each meal since the day of admission. The resident was weighed on 6/28/11 the day of admission and weighed 122 lbs. The weight trend documented was as follows: 06/28/11 - 122 lbs. 07/05/11 - 122 lbs. 07/12/11 - 121 lbs. 07/19/11 - 120 lbs. 07/26/11 - 121 lbs. 08/2011 - 119 lbs. 09/2011 - 102 lbs. (weight loss of 17 lbs. in 1 month / 14.2 % weight loss). The death certificate was reviewed on 1/12/12. Under the immediate cause of death, "ACUTE RESPIRATORY FAILURE" was listed. "FAILURE TO THRIVE (or weight faltering, meaning insufficient weight gain or inappropriate weight loss)" was listed as one of the conditions leading to the acute respiratory failure. Therefore the facility failed to ensure one resident maintained acceptable nutritional parameters which may have contributed to the resident dying on 9/2/11.The above violation demonstrated either imminent danger or serious harm would result or a substantial probability that serious physical harm would result. |
| 120001442 |
SIERRA VALLEY REHABILITATION CENTER |
120009512 |
B |
28-Nov-12 |
06DQ11 |
3343 |
T22 DIV5 CH3 ART5 - 72523(a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On February 16, 2010, an unannounced visit was made to the facility to investigate a self-reported incident involving a patient who fell and sustained a laceration on her forehead which required sutures. Based on interview and record review, the facility failed to implement their written patient care policy and procedure indicating two-person assistance in turning a helpless patient, resulting in one patient (Patient A) falling out of bed during her care and sustaining a laceration on her forehead which required sutures.The clinical record for Patient A was reviewed on February 16, 2010 at 10:40 AM.The ADMISSION INFORMATION SHEET updated September 30, 2009, indicated Patient A was admitted to the facility with diagnoses including dementia, a history of stroke and contractures of her arms (her arms were contracted to her chest, meaning they were "frozen" in place and not easily moved from that position).During an interview with Staff 4, on February 16, 2010 at 10:02 AM, they stated that on January 30, 2010, "I was standing on the left side of the bed; I pulled the resident towards me with the pink pad, rolled her to her right side. Her arm bumped the top of the rail and the railing flung straight down. The resident kept on rolling and fell." When asked if she checked the side rail and ensured its locking mechanism was functional, she stated, "It looked like it was secure, but it wasn't." Staff 4 stated she did not check the integrity of the side rail because this was the maintenance department's job and not hers. Staff 4 also stated she was aware Patient A required total assistance but did not know a two-plus-person physical assistance was required to turn her in bed. The annual MDS (Minimum Data Set, a periodic assessment of the patient) dated July 15, 2009, indicated Patient A had limited range of motion (ability to move her joints normally) on her right side, and was totally dependent in all activities of daily living, such as bed mobility. According to the MDS, a "two+ person physical assist" was required for these activities.During an interview with the Director of Staff Development (Staff 2) on February 16, 2010 at 10:25 AM, she stated Staff 4 wrote on Resident A's ADL flow sheet the number "4" (indicating "total assistance" was needed) on all the activities listed on the flow sheet. She stated the facility's policy required two-person assist for "4s."The facility policy and procedure titled "BODY POSTURE AND MECHANICS" dated March 31, 2009 read in part ... "C. HOW TO TURN A HELPLESS RESIDENT - 1. Take two pillows to side of bed and place them near your assistant. 2. Slip your hand under resident's shoulders and hips, and have your assistant to do the same on her side. 6. Have your assistant place pillows behind resident's back." The facility failed to implement their written patient care policy and procedure indicating two-person assistance in turning a helpless patient, resulting in one patient (Patient A) falling out of bed during her care and sustaining a laceration on her forehead which required sutures.This violation had a direct relationship to the health, safety, or security of patients. |
| 630011298 |
Steele's Quality Living - Vassar |
120010125 |
B |
23-Oct-13 |
WSFX11 |
2707 |
W127-483.420(a)(5) Protection of Clients? Rights (a) The facility must ensure the rights of all clients. Therefore, the facility must: (5) Ensure that clients are not subjected to physical, verbal sexual or psychological abuse or punishment.On 8/15/12 at 8:40 AM, an unannounced visit was made to the facility to investigate an entity reported incident of alleged employee to client abuse.Based on interview and record review, the facility failed to ensure Client 1 was treated with dignity, respect and not subjected to physical abuse. This had the potential to cause physical and/or emotional trauma.During an interview with the Qualified Mental Retardation Professional (QMRP), on 8/15/12, at 9:15 AM, she stated Direct Care Assistant (DCA) 2 reported the incident that happened on 8/9/12 between Client 1 and DCA 1. The QMRP also stated she did the investigation and talked to DCA 1 and DCA 1 admitted the allegation of abuse and said ?Yes, I did it.?During a review of the clinical record for Client 1, the nursing notes dated 8/9/12, indicated Client 1 did not want to take a shower. DCA 1 took Client 1?s dolls and threw in the garbage can. DCA 1 also wet Client 1?s gown with water while Client 1 was sitting in the toilet.During an interview with DCA 2, on 8/23/12, at 10:42 AM, she stated she and DCA 1 worked night shift when the incident happened. On 8/9/12, at 5 AM, DCA 1 woke up Client 1 to give the 6 AM medication. DCA 2 was in the kitchen when she heard DCA 1 and Client 1 arguing because Client 1 did not want to take a shower. DCA 1 told Client 1, she would have to take a shower whether she liked it or not. DCA 1 took Client 1?s dolls and threw them in the garbage can. DCA 1 also grabbed Client 1?s purse from her hands. DCA 2 also stated Client 1 refused the outfit that DCA 1 prepared for her but DCA 1 told Client 1 ?You will wear what I picked for you to wear.? When Client 1 was sitting on the toilet seat, DCA 1 grabbed the shower hose and wet Client 1?s hair and gown with water. DCA 2 told DCA 1 what she was doing was wrong and that she was going to report the incident to their Boss (QMRP). DCA 1 told DCA 2 that she was burned out and said she may do what she needed to do. DCA 2 also stated ?I think it?s happening a lot.?The facility policy and procedure titled ? CLIENT ABUSE AND NEGLECT? indicated under ?I. GENERAL: The facility prohibit both client abuse and neglect, whether perpetrated by staff, volunteers, family members, friends, other clients, associates of outside agencies, or the general public.?Therefore, the facility failed to protect Client 1 from abuse from staff.This violation had a direct relationship to the health, safety or security of the client. |
| 120001442 |
SIERRA VALLEY REHABILITATION CENTER |
120010127 |
B |
16-Sep-13 |
W98B11 |
3561 |
72315(b). Nursing Service - Patient Care. Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. On December 12, 2012 at 12:30 PM, an unannounced visit was made to the facility to investigate a facility reported incident regarding employee to patient abuse.Based on observation, interview, and record review, the facility failed to protect one patient (1) from physical abuse from an employee. Patient 1 was a 71 year old female admitted to the facility for rehabilitation services. Patient 1 had a diagnosis of Chronic Obstructive Pulmonary Disease (disease of the lungs which causes severe shortness of breath) and general weakness. Findings: During an observation and concurrent interview of Patient 1, on 12/12/12 at 2:45 PM, she was lying in her bed, appropriately dressed, alert and oriented. Patient 1 described she was in physical therapy when her oxygen tank became empty and there was no oxygen tank to replace it. She was taken to her room by the Occupational Therapist (OT). Patient 1 stated "she didn't seem to be in any hurry and I told her to hurry I was out of breath, and OT told me to shut up." Patient 1 stated while in the room OT did not get her oxygen hooked up quickly and she was feeling very short of breath and was upset. Patient I stated "OT told me to just do it myself and started walking out of the room. I called her a bitch, and OT turned around and came back to me and slapped me on my arm and walked away. I started yelling at her for hitting me and then the nurse came in." Patient 1 described the nurse took care of her oxygen and OT left the room. During an interview with Patient 1's roommate (Patient 2) on 12/12/12 at 2:45 PM, she confirmed Patient 1's story. Patient 2 stated "I don't think OT knew I was sitting here in the corner watching. Patient 1 was short of breath and telling OT to hurry but the therapist didn't appear too concerned. OT got upset and started to leave and Patient 1 called her a bitch. OT came back into the room and walked over and slapped her on the arm and then left the room."During an interview with Licensed Vocational Nurse (LVN 1) on 1212/12 at 2:30 PM, she stated "I heard Patient 1 yelling 'you slapped me'. I quickly went into the room and asked what happened. Patient 1 said OT hit her and Patient 2 confirmed the incident. OT was standing behind Patient 1's wheelchair and she said 'I didn't do anything to her' and walked out of the room."During a review of the clinical record for Patient 1 on 12/12/12, the Care Plan titled "Ineffective airway clearance Potential for shortness of breath", dated 11/23/12, indicated a plan to "Monitor for and be present to render support to prevent anxiety if episode of shortness of breath occurs."A "Nurses Note", dated 12/5/12 at 3:15 PM, by the Director of Nurses (DON) indicated "Due to information obtained from Resident and witness statement from roommate, and also that of licensed nurse.....finding that alleged abuse against therapist...is in fact substantiated."The contract between the Physical Therapy Department, "Orthopedic and Neurological Rehabilitation, Inc. (ONR)" was reviewed on 1/7/13 at 5PM. Under the Duties and Obligations section b. Compliance with Law, "ORN will provide services to facility's patients under the terms and conditions of this agreement, applicable requirements of Federal and State laws and the conditions of participation ...." Therefore; the facility failed to protect one patient from physical abuse from an employee. |
| 630003241 |
Steele's Visions - Hatch |
120010168 |
B |
23-Oct-13 |
GIXF11 |
3833 |
CALIFORNIA WELFARE AND INSTITUTIONS CODE 4502(h) Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. On April 30, 2012, at 10:30 AM, an unannounced visit was made to investigate an allegation of staff to client abuse. Based on interview and record review, the facility failed to protect one client from physical abuse from a staff member. This failure resulted in Client A receiving two bruises to his forearm. The clinical record for Client A was reviewed on 4/30/12 at 10:40 AM. Client A was described a 72 year old male, with diagnosis of Autistic Disorder, developmentally disabled, inappropriate verbalization, and anger management. He was alert and oriented to name, date and place and able to communicate his needs. The clinical notes dated 4/28/12 indicated Client A showed the evening shift staff the bruises on his left forearm. He indicated it was a result of Direct Care Staff (DCS 1) grabbing his arm earlier in the day.During an interview with Direct Care Staff 2 (DCS 2) on 4/30/12, at 11:45 AM, she stated she was a short distance away but did witness part of the interaction between Client A and DCS 1. She heard DCS 1 telling Client A to give her what he had just put in his mouth and that he should not pick things up off the ground and put them in his mouth. DCS 1 told Client A she would call the house manager if he did not give it to her. DCS 2 said Client A gave DCS 1 the toothpick but reached in his pocket and put another one in his mouth and walked away. DCS 2 stated the two began arguing but she did not see DCS 1 grab his arm.During an interview and concurrent observation, with Client A on 4/30/12, at 5 PM, he stated he had toothpicks in his pocket and had put one in his mouth (on the day of the incident 4/28/12). He stated DCS 1 told him to give her the toothpick and not to put things in his mouth from the ground. He did give her the toothpick but put another one from his pocket into his mouth and walked away. DCS 1 came after him yelling at him and "she demanded I give it to her." Client A stated DCS 1 instructed him to stand still and then started searching through all his pockets. He would not let her put her hands in his jacket pocket so she grabbed his arm and tried to pull it out. She was mad and yelling at him. She was hurting his arm and she finally let go and said the outing was over. They returned to the house. He then showed the evening staff the marks she left on his arm. Observation of Client A's arms revealed swelling and two bruises approximately 1 1/2 inches long by 1/2 inch wide and separated by about 1/2 inch and then one small round bruise next to the longer ones.During an interview with DCS 1, on 5/2/12, at 10:10 AM, she admitted to grabbing Client A's arm in an attempt to pull his hand out of his pocket and take the items he was concealing. DCS 1 admitted to searching Client A's pockets.Therefore the facility failed to protect Client A from physical abuse from a Direct Care Staff member when she grabbed him by the arm causing bruises. The above violation has a direct relationship to the health, safety or security of the client which constitutes a Class B violation. |
| 120001442 |
SIERRA VALLEY REHABILITATION CENTER |
120010412 |
B |
05-Feb-14 |
SV8N11 |
2470 |
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.(c) For purposes of this section, "abuse" shall mean any of the conduct described in subdivisions (a) and (b) of Section 15610.07 of the Welfare and Institutions Code.(d) This section shall not change any reporting requirements under Section 15630 of the Welfare and Institutions Code, or as otherwise specified in the Elder Abuse and Dependent Adult Civil Protection Act, Chapter 11 (commencing with Section 15600) of Part 3 of Division 9 of the Welfare and Institutions Code.The facility failed to report an allegation of abuse to the California Department of Public Health within 24 hours.On 7/16/12, at 12:04 PM, the department received a faxed Facility Reported Event. The report indicated Certified Nursing Assistant 1 (CNA 1) had reported that CNA 2 had been rough with Resident 1 during care. CNA 1 alleged that CNA 2 had twisted Resident 1's arm during care.The alleged abuse had occurred approximately one month prior to being reported.During an interview with the Assistant Administrator on 7/16/12 at 4:30 PM, she stated, CNA (Certified Nursing Assistant) 1 had accused CNA 2 of being rough with patients. She stated CNA 1 waited a month to report the incident. CNA 1 could not give an exact date of the incident. She reported only that it was about a month ago. During an interview with the Director of Staff Development on 10/17/12 at 10:30 a.m., she stated, "At first CNA 1 said she witnessed abuse, and then she stated she had only heard a moan from the resident behind the curtain."During a review of the personnel file of CNA 1, she was hired 3/27/12 and had the facility's abuse training/reporting on 3/28/12.The facility policy titled "Abuse Policy- Investigative and Prohibitive Protocol"; undated, indicated that it was the basic responsibility of every employee to ensure the safety and wellbeing of Residents. It also indicated that Abuse must be reported if it is observed or if staff has knowledge of an incident that reasonably appears to be abuse.Therefore, the facility failed to report an allegation of abuse to the State Survey and Certification agency.In accordance with Health and Safety Code Section 1418.91, this violation is a Class B violation. |
| 120001442 |
SIERRA VALLEY REHABILITATION CENTER |
120010416 |
B |
05-Feb-14 |
QDNV11 |
2962 |
483.13The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to follow their abuse policy and procedure, when the Director of Nurses failed to initiate an investigation after Resident 1 was noted to have fingertip size bruising around both of his nipples.Resident 1 was a 74 year old male who was admitted to the facility with diagnosis including Dementia and General Weakness. On 9/28/12 at 5:50 PM, an unannounced visit was made to the facility to investigate this entity reported incident of injuries of unknown origin. During an interview with the Charge Nurse on 9/28/12 at 5:50 PM, she stated she was the Registered Nurse in charge of the facility. The Charge Nurse was not aware of Resident 1's bruising; she was unaware of any investigation to determine the cause of the bruising. During a subsequent interview with the Charge Nurse, on 9/29/12, at 4:30 PM, she stated the Administrator and Director of Nursing work during the day, and if anything is going on they make her aware of it when she comes to work in the afternoon. She stated she had not been informed of the bruising on Resident 1. During a telephone interview with the Director of Nurses, on 9/28/12, at 6 PM, she stated she was sick but came into the facility earlier in the day to report Resident 1's bruising to the Department of Public Health. She stated she left the facility without conducting any further investigation. During an observation and interview with the Licensed Vocational Nurse (LVN) 1 on 9/28/12 at 6:20 PM, in Resident 1's room, Resident 1 was observed resting in bed with both eyes closed. Resident 1 did not respond to verbal greeting, and LVN 1 stated the resident was not verbal. Several small bruises (3 on the right breast, 5 on the left breast), ranging from 1/2 to 3/4 inches, reddish to light brown in color, were observed around both nipples. Some bruising around the left nipple had yellowish borders.During a review of the clinical record for Resident 1, MDS (Minimum Data Set, a tool used to document a resident's assessment), dated 7/16/12, indicated Resident 1 was rarely able to make himself understood and was dependent upon staff for his activities of daily living. Nurses Notes, dated 9/28/12, at 12:15 PM, indicated a family member of Resident 1 had notified staff of bruising to Resident 1's chest. Staff inspected the area and noted several small bruises close to both of Resident 1's nipples.The facility policy and procedure titled Investigative and Prohibitive Protocol, undated, indicated facility staff is to ensure that all alleged violations including injuries of unknown source are to be reported immediately, and all violations/alleged violations will be thoroughly investigated and documented.This violation had a direct or immediate relationship to the health, safety, or security of Resident 1. |
| 120001544 |
Sierra Vista Residential Care Home #3 |
120010423 |
B |
06-Feb-14 |
SD3Z11 |
5648 |
(W150) ?42 CFR 483.420 (d) (1) (i) Staff of the facility must not use physical, verbal, sexual or psychological abuse or punishment. On 5/15/12, an unannounced visit was made to the facility to investigate the facility's report of alleged and/or suspected abuse toward a facility client from a staff person.Based on interview and record review, the facility failed to prevent physical and verbal abuse from one facility employee towards three clients (A, B, & C), and additionally, failed to protect Client A from psychological abuse. This violated the rights of the three clients involved (A, B, & C).Findings: A facility document addressed to the Department received on 5/14/12 and written by the facility Registered Nurse Consultant / Administrator 3 (RNC/A 3) indicated Direct Care Staff 2 (DCS 2) had observed Direct Care Staff 1 (DCS 1) both verbally and physically abusing Clients A, B, & C, all during the evening of 5/13/12.Per the document, DCS 2 observed DCS 1 shoving Client A in the back, called Client A a profane name, ("'lil f****"), and intentionally hid Client A's favorite toys from him. The document further indicated DCS 2 observed DCS 1 "aggressively push" Client B's hands and fingers out of his mouth.Regarding Client C, the document further indicated DCS 1 "would slap his hand out of his mouth over and over again", again witnessed by DCS 2.The document also indicated DCS 2 observed DCS 1 "use vulgar language and mean faces" towards all three clients (A, B, & C). The clinical records for Clients A, B, & C were reviewed. The document titled "Client Identification Information" indicated each client was intellectually disabled and required assistance with activities of daily living.A letter written by DCS 2 on 5/13/12 addressed to RNC/A 3 and the facility Program Manager (PM 4) was reviewed and read, in part, that DCS 1 that evening was "constantly aggressive with the guys... She shoved [Client A] and called him a 'lil f*****.' And, she hid his friends (a collection of toys and action figures) from him... When (Client B) would put his hands/fingers in his mouth she would aggressively push them out of his mouth... And when (Client C) would put his hand in his mouth she would slap his hand out of his mouth over and over again. She will continuously yell at the clients to see if they'll actually do what she wants. She'll use vulgar language and mean faces towards the guys. To be honest, it makes me sick to my stomach at the way she treats the guys. It's disturbing, crude, and unnecessary." During an interview with RNC/A 3 on 5/15/12 at 12:30 PM, she indicated DCS 1's removal of Client A's "friends" (a collection of small toys and action figures) would have caused him "distress". RNC/A 3 stated Client A knows if his "friends" are not there, he looks for them..." RNC/A 3 stated DCS 1's employment with the facility was terminated that day, 5/15/12, due to these behaviors, and we "just felt better with her not in the home." During an interview with DCS 2 on 5/15/12 at 1:15 PM, her letter of 5/13/12 was reviewed, and she recalled it as accurate. DCS 2 added as the evening of 5/13/12 progressed, DCS 1 "was getting increasingly upset. I'd never seen her like this before, where she puts her hands on someone." DCS 2 stated that without his "friends", Client A walked about the house that evening looking for them, and "Absolutely, he was upset by this. He treasures these toys the most." DCS 2 stated she herself returned his "friends" back to him when DCS 1 was giving another client a shower.During an interview with DCS 1 on 5/17/12 at 3:50 PM, she stated "I did not do abuse." DCS 1 stated during the evening of 5/13/12, she did not call Client A a "lil' f****", she had called him a "little trucker." DCS 1 stated "little trucker" is not a nickname she normally uses. She stated she did not take Client A's "friends" from his person, she took them "from the dining room table, and I put them on top of the fridge, and he got them from there, himself." DCS 1 stated she had put the toys on top of the refrigerator so Client A "could do range-of-motion, you know, put his hands over his head, to get to the toys. I saw him get the toys back himself." Regarding Client B, she indicated nobody had asked her about Client B, and therefore had no response. Regarding Client C, DCS 1 stated she had tripped over her pants, which caused her to push Client C's hands out of his mouth. During an interview with RNC/A 3 on 5/15/12 at 12:20 PM, she stated DCS 1 had been employed by the facility since 2008, and had been "talked to" in the past for her "gruff, rough voice, and demeanor", and that her demeanor could be perceived by others as a problem.During an interview with Direct Care Staff 5 (DCS 5) on 5/15/12 at 12:45 PM, she stated she worked with DCS 1 for about 30 minutes on the evening of 5/13/12, and while she did not witness any physical abuse, she did recall her "gruff verbal demeanor."The personnel file for DCS 1 was reviewed on 5/15/12 at 1 PM. Written in an employee evaluation dated 7/5/11 by previous supervisors was the notation "need to improve with getting along with others" and "seems to get frustrated with clients at times." DCS 1 had received an "Employee Warning" on 6/24/11 for throwing keys at another employee.The facility failed to protect Client A from physical abuse, verbal abuse, and psychological abuse. The facility failed to protect Clients B and C from physical and verbal abuse.The above violations caused, or occurred under circumstances likely to cause, significant humiliation, indignity, anxiety, or other emotional trauma to Clients A, B, & C. Page 1 of 4 |
| 120001442 |
SIERRA VALLEY REHABILITATION CENTER |
120010542 |
B |
20-Mar-14 |
RYG211 |
7101 |
F323 ?483.25(h) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. On September 25, 2012 at 9:45 AM, an unannounced visit was made to the facility to investigate a facility reported incident regarding accidents.Based on observation, interview, and record review, the facility failed to protect one resident (Resident 1) from injury when did not follow their own smoking policy. This led to Resident 1 receiving burns to his face. Resident 1 was a 61 year old male, admitted to the facility on 4/18/12, with the diagnosis of left sided weakness, diabetes, bone cancer and was on hospice care. He used a wheelchair to move about the facility and went outside to smoke.Findings: During an observation and interview with Resident 1 on 9/25/12, at 1:45 PM, a lighter was found on his bedside table. Resident 1 was partially lying and sitting in bed with his hair draping into his face. He had an abrasion on the left side of his face and his hair was shorter on the left side. Resident 1 stated he went out to smoke and forgot his lighter so he asked another resident (2) to light his cigarette. While Resident 2 was lighting the cigarette the lighter caught Resident 1's hair on fire and burned the side of his left cheek. Resident 1 said the lighter on the bedside table was his and that was where he kept it. Resident 1 sated, "No one told me I couldn't keep it with me."During an interview with Resident 1's roommate (3) on 9/25/12, at 1:50 PM he stated "Resident 1 always falls forward in his wheelchair when he is out smoking and his hair hangs down into his face." At this time, Resident 3 showed his tobacco supplies and demonstrated how to make cigarettes in his room. These supplies included tobacco, wrappers, and a machine to roll cigarettes. Resident 3 stated he shared his handmade cigarettes with Resident 1 when he didn't have any.During a concurrent observation and interview with Resident 2 on 9/25/12, at 2:05 PM, he was sitting outside. He could not move his left hand and his right hand was trembling. He was not able to answer questions but only mumbled.During a review of Resident 1's clinical record, his "Minimum Data Set (MDS, a resident assessment tool)," dated 7/29/12, indicated Resident 1 required "extensive assistance with bed mobility, transfers, locomotion off the unit, dressing, eating, toilet use and bathing." The assessment described Resident 1 as "Not steady, only able to stabilize with staff assistance in transitions and walking and required a wheel chair."The "Resident-Data Collection," dated 4/18/12, indicated Resident 1 had left-sided weakness and was forgetful and displayed impaired decision-making ability. The "Nurse's Note" dated 9/22/12, at 12:50 PM documented, "while out on patio, Resident 1 asked another resident to light his cigarette and singed hair on left side and has blister." The Care Plan titled "Potential for development of pressure..." indicated Resident 1 had poor balance while sitting. Resident 1's "Inventory List" included a lighter. Resident 1's clinical record did not include a care plan for smoking, a smoking assessment, or a smoking indication on the outside of his chart.During a review of the clinical record for Resident 2 on 9/25/12, at 10:40 AM, there was no smoking indication on the outside of his clinical record, and no smoking assessment. The weekly "Nurses' Progress Note," dated 9/2/12 thru 9/19/12, indicated Resident 2 had a memory problem, he communicated by signs/gestures/ sounds and he had left sided weakness. Resident 2 had a "Resident Care Plan" for cognitive loss, manifested by "confusion and disorientation with short and long term memory impairment." The MDS dated 7/12/12, "Section C1300. Signs and Symptoms of Delirium" indicated resident's behaviors of inattention and disorganized thinking as "behavior continuously present, does not fluctuate."The facility policy and procedure titled "Smoking Policy" undated, indicated: 1. "All smoking supplies (this includes, but is not limited to tobacco, matches, lighters, lighter fluid, etc.) Shall not be kept at nursing station. Smoking supplies shall be labeled with patient's name, room and bed number, and shall be stored in a suitable cabinet provided for this purpose." 2. "Smoking without supervision: Ambulatory patient who can go to designated smoking areas without assistance. Patients who can transfer to and from wheelchair and propel themselves without assistance."3. "Smoking with supervision (will require smoking apron) Non-ambulatory patients who need assistance with wheelchairs, but who are alert and do not need continuing and constant supervision. The nursing staff will periodically observe the designated smoking locations." 4. "Smoking with close observation (requires smoking apron) Patients with primary diagnosis related to neuromuscular disorders, i.e., Parkinson's Disease, or psychiatric disorders related to organic brain diseases, and those patients with demonstrated periods of confusion and disorientation." 5. "The Facility DNS (DON) or her designee shall indicate on the outside front cover of the medical chart, and/or nursing care plan, the smoking designation of the patient. This should be identified in the same manner as "allergy" determination." During an interview with Licensed Vocational Nurse (LVN 1) on 9/25/12 at 11 AM she stated they do not have a smoking cabinet, but keep all resident smoking supplies in the medication carts. LVN 1 looked and did not have any smoking supplies for Resident 1, 2 or 3. During an interview with LVN 2, on 9/25/12 at 11:15 AM, she confirmed smoking supplied are kept in the medication carts and verified she does not have any smoking supplies in her medication cart.During an interview with the Director of Nurses (DON) on 9/25/12 at 2:15, she stated they do not have a cabinet designated for smoking supplies but keep in the Medication carts for convenience of staff. The DON indicated the smoking areas are on the patio and outback in the parking lot under the trees. She indicated the staff also smoke under the trees and are able to observe residents during their smoking times. The DON stated "we do not have smoking monitors because the 3 residents who smoke are alert and can go on their own." The DON indicated residents do not wear the smoking aprons by their own choice. The DON stated she was not aware Resident 1 kept a lighter at bedside and Resident 3 had supplies at bedside to make cigarettes. She stated she was not aware there was no smoking assessment or chart identifier for Resident 1 & 2.The facility failed to implement their smoking policies and procedures by failing to: 1. Secure smoking supplies properly. 2. Assess residents to determine the required level of supervision during smoking. 3. Post the smoking designation of the resident on the front cover of the medical chart. These violations had a direct relationship to the health, safety or security of the residents. |
| 150000229 |
SONOMA DEVELOPMENTAL CENTER D/P SNF |
150007383 |
B |
15-Mar-12 |
37CY11 |
12483 |
TITLE 22, SECTION 72331 (a)(2) NURSING SERVICES - GENERAL (a) Nursing services 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. TITLE 22, SECTION 72523 (a) PATIENT CARE POLICIES AND PROCEDURES (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility violated the above regulations by not providing cardiopulmonary resuscitation (CPR) promptly as per facility policy, as follows: On 3/16/10, the facility notified the California Department of Public Health by written notice that on 3/14/10, at 8:46 a.m., Client 1 was found in bed without a pulse or respirations. Staff B initially thought that Client 1 was a "Do Not Resuscitate" and reported an expired client with a DNR to the facility's operator and to the physician. Upon the physician's arrival on the unit, it was noted that Client 1 was a "Full Code." The physician called a medical emergency and CPR was initiated. Client 1 did not respond to resuscitation measures and was pronounced dead by the physician at 9:04 a.m., on 3/14/10. Review of Client 1's medical record on 3/25/10, at 11 a.m., revealed that Client 1 was a male, 62 years of age admitted to the facility on 5/4/87. He had diagnoses that included: profound mental retardation, post cerebral vascular accident (stroke) and dysphagia (difficulty in swallowing) requiring a gastrostomy tube (a tube inserted into the stomach for the purpose of administering food, fluids and medications). The MDS (Minimum Data Set), a resident assessment tool dated 2/2/10, indicated that the reason for the assessment was for a significant change in Client 1's health status. The facility's assessment of Client 1 indicated that he was unable to speak, unable to make himself understood and unable to understand others. Under Section A, #10 "Advanced Directives" the MDS indicated that there were no advance directives (consents given by the patient regarding the withholding or withdrawing of life-sustaining procedures and/or life-reviving procedures) in place for Client 1. Facility document titled Nursing Evaluation Assessment Annual dated 1/27/10 indicated that Client 1 was a Full Code (life-reviving attempts such as cardiopulmonary resuscitation, or other therapeutic procedures will be done to maintain life). Review of the Physician Orders dated 2/17/10 and 3/9/10, revealed that there was no reference regarding a "Do Not Resuscitate" order in place for Client 1. Facility document titled Nursing Mortality Report dated 4/9/10, at 2:20 p.m., under the title of "Discussion" indicated that Client 1 had suffered a cerebral vascular accident (CVA) in July of 2008. In April of 2009, he continued to decline in function and required increased nursing care related to the CVA. On 2/9/10, the Team met for a Significant Change Conference to address his progressive health decline. Code status was not addressed at this meeting and Client 1 remained a "Full Code." According to the Nursing Mortality Report dated 4/9/10, Client 1 was found in bed without a pulse or respirations on 3/14/10, at 8:46 a.m. Unit staff did not know Client 1's code status and assumed that he was a DNR and subsequently CPR was not initiated and Medical Emergency was not alerted until the physician arrived on the unit and stated that "It needed to happen." The facility Telephone Operator Log dated 3/14/10, at 8:47 a.m., indicated that on "Line 3" Staff B had called and reported that Client 1 was deceased. The telephone operator had documented that she had asked Staff B if there was a DNR in place and that Staff B stated to her, "Neah, but it wouldn't do any good, client already gone." The facility operator documented at 8:54 a.m. that Nelson C staff had called and stated that the physician requested a code team to the unit. The telephone operator also documented that there was a delay in notifying the Fire Dispatch Service due to all the confusion. At 9:04 a.m., the same facility operator documented that the client was pronounced deceased from possible cardiac disease, "NO DNR." On 6/17/10, at 1:30 p.m., Staff A was interviewed. Staff A stated that Client 1's health had not been stable since he suffered a cerebral vascular accident (stroke) in 2008. Staff A stated that Client 1 required total nursing care for all his personal needs. Staff A stated that on 3/14/10, between 6:45 a.m., and 7:30 a.m., he was in Client 1's room attending to his personal care. Staff A stated that Client 1 was alive and did not appear to be in any distress at that time. Staff A stated that at approximately 8:46 a.m., Staff B went into Client 1's room to start his gastrostomy feeding. Staff A stated that Staff B called out to him to come into Client 1's room to assist him in starting CPR on Client 1, as Staff B had observed Client 1 without respirations or a pulse. Staff A stated that he had just began chest compressions, when Staff B stated to him, "I'm not sure if he is a DNR or not. I'm confused." Staff A stated that Staff B left Client 1's room at that time to call the facility operator and request the MOD (medical officer of the day) to the unit. Staff A stated that he immediately stopped CPR when Staff B left Client 1's room to call the operator. Staff A stated that CPR was not started until the physician arrived on the unit. On 6/17/10, at 2:30 p.m., Staff B was interviewed. Staff B stated that on 3/14/10, he was 2 hours late getting to work (from 6:30 a.m. to 8:30 a.m.) and did not report on the day shift until approximately 8:30 a.m. Staff B stated that he should have been on the unit by 6:30 a.m. Staff B stated that he did not do his rounds and check his residents when he first came on the unit, as he was late. Staff B stated that rounds should have been done, however he decided to start the medication pass instead. Staff B stated that he went into Client 1's room and found him unresponsive. Staff B stated that he thought Client 1 had died, however he was not sure of Client 1's code status. Staff B stated that he called out to Staff A to come to Client 1's room and help with CPR. Staff B stated that they started CPR on Client 1 and within a few minutes, he told Staff A that he was confused on Client 1's code status and told Staff A that he thought Client 1 was a DNR. Staff B stated that they stopped CPR at that time, and he went out to the nursing desk to call the facility operator and inform her that a client had died and was a DNR. Staff B stated, "I really thought that the client was a DNR as his health had declined severely. The Team held a Significant Change meeting and discussed the possibility of changing his code status from a "Full Code" to a DNR status. I think that this is where I got confused on his code status. When I came out of his room to call for the MOD, there was a chart left open on the desk with a DNR in place and I assumed that it was this client's chart. I made a terrible mistake." Staff B stated that when the physician arrived on the unit, that he asked Staff B to check Client 1's chart for his code status. Staff B stated that after he checked the physician's orders, he realized that Client 1 was a "Full Code" as Client 1 did not have a DNR order in place. On 6/17/10, at 4:30 p.m., Staff C was interviewed. Staff C stated that on 3/14/10 during the night shift, Client 1 did not have any clinical concerns and was alive at 7 a.m.On 8/16/10, at 9 a.m., per telephone, the MOD was interviewed. The MOD stated that on 3/14/10, at 8:47 a.m., that he had received a message that Staff B had requested the MOD to the unit STAT (to be done immediately) as CPR had been initiated on Client 1. The MOD stated that when he arrived on the unit at 8:52 a.m., approximately 5 minutes after receiving the call, he observed Staff A and Staff B sitting at the nurses' desk. The unit was quiet and there were no signs that there had been a problem with a client. The MOD stated that Staff B told him that Client 1 had expired and that he was a DNR. The MOD stated that upon entering Client 1's room, he observed that the head of Client 1's bed was in the upright position. No back board was observed under Client 1 and the crash cart and oxygen were not at his bedside. The MOD stated, "My concern is, was CPR ever started and if it was, why was it stopped?" The MOD stated that he left Client 1's room and reviewed his chart - a DNR order was not found. The MOD stated that he informed Staff B that Client 1 was a "Full Code." The MOD stated that he told Staff B to call a Code Blue (a medical emergency) at 8:54 a.m., and he (the MOD) immediately started chest compressions. The MOD stated that the Code Blue Team arrived on the unit at 8:57 a.m., and CPR was continued for another 7 minutes, however Client 1 did not respond to the resuscitation and he was pronounced expired at 9:04 a.m. Facility document titled Department of Developmental Services - Office of Protective Services dated 7/15/10, was reviewed on 8/16/10, at 10 a.m. The document indicated that an independent investigation was completed by a Special Investigator. Under "Findings" according to the report, during the course of the investigation, Staff B acknowledged that he had falsified the 24 hour log as it applies to rounds at 6:30 a.m., and 7:30 a.m., and immediately started the medication pass upon arrival on the unit. Furthermore, according to the report, it was documented that Staff B did not arrive on the unit until approximately 7:15 a.m. Staff B stated that he did not personally check on Client 1 at 6:30 a.m., and 7:30 a.m., as he indicated on the 24 hour log. According to the report, during the course of the investigation, Staff A acknowledged that after performing CPR for several minutes on Client 1, Staff B discontinued CPR without relief or directions of a physician. According to the report, the allegation of neglect was substantiated - evidence supported the allegation. After the interview of Staff B on 6/17/10, at 2:30 p.m., and review of the facility document titled Department of Developmental Services - Office of Protective Services on 8/16/10, at 10 a.m., there appeared to be a discrepancy regarding the time Staff B stated that he had arrived on the unit on 3/14/10 to begin the morning shift. According to Staff B during the interview, he stated that he did not arrive on the unit until 8:30 a.m. According to the documentation on the Office of Protective Services report, it was documented that Staff B stated that he arrived on the unit at 7:15 a.m. Facility policy number P917, Medical Emergency Response dated November 2009 was reviewed on 8/16/10, at 10:30 a.m. Under the section titled "Client Medical Emergencies" it indicated that when emergency medical services are needed, the SDC (facility) staff shall: Initiate basic life support (BLS)/first aide as per the American Heart Association Guidelines. According to the American Heart Association basic life support guidelines, the AHA's basic life support guidelines are detailed by the chain of survival. The chain of survival is a protocol that helps the first responders and civilians provide essential care to a victim of a choking or respiratory arrest through early CPR. Facility policy number 492, Bioethics: Life-Sustaining Procedures: Do Not Resuscitate (DNR) Orders dated October 2008 was reviewed on 8/16/10, at 11 a.m. Under the section titled, "Guidelines" - Unexpected Life-Threatening Event, it indicated that in the absence of a "Do Not Resuscitate (DNR) order," CPR will be initiated without a physician's order when cardiac or respiratory arrest is recognized. An interview with the MOD per telephone on 8/16/10, at 1:30 p.m., who responded to Client 1's bedside on 3/14/10 at 8:52 a.m., indicated that CPR was not initiated timely and in the correct manner per facility policy and the American Heart Association Guidelines. The MOD stated, "CPR should not have been stopped once it was initiated, unless ordered by the physician." The facility staff failed to provide cardiopulmonary resuscitation (CPR) promptly as per facility policy and the American Heart Association Guidelines, when Client 1 was found in bed unresponsive, without a pulse or respirations on 3/14/10, at 8:46 a.m. This failure had a direct or immediate relationship to the health, safety, and security of patients. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150008152 |
A |
13-Apr-12 |
YSDN11 |
6230 |
TITLE 22, SECTION 76315 (b) DEVELOPMENTAL PROGRAM SERVICES - INDIVIDUAL PROGRAM PLAN (b) The individual program plan shall be implemented as written. TITLE 22, SECTION 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. The facility failed to comply with the above regulations by failing to keep Client 1 free from the potential harm by failing to follow Client 1's Mobility Plan, which indicates that Client 1 requires staff assistance while in her wheelchair for outdoor propelling in uneven terrain. Further, the facility failed to implement its' own policy to provide close supervision for Client 1 during an outdoor field trip, as follows: On 10/21/10, the facility notified the California Department of Public Health by written notice that on 10/16/10, Client 1 had been injured during an outdoor field trip. The notice indicated "..... Resident waiting for van while at Camp Villa, unlocked her brakes on her wheelchair and began rolling away. Staff was unable to stop her before her wheelchair rolled down an embankment and tipped over. Resident sustained nose bleed, abrasion to forehead and scratches to her left arm. She was transferred to an acute hospital by ambulance where she was diagnosed with C1 fracture, broken nose and facial bruising." Clinical record and document review starting on 11/8/10 indicated: Client 1 was a female, 60 years of age admitted to the facility on 7/31/1950. She had diagnoses that include Seizures, Osteoporosis, and Severe Mental Retardation. The facility's assessment of Client 1 indicated that she lacked safety awareness and must be supervised when walking with her walker and her helmet. She was able to propel her own wheelchair however required assistance with long distances, going up and down hills or maneuvering on uneven terrain. Facility document titled Recreation/Leisure Evaluation dated 6/25/10 indicated that Client 1was at risk for falls and required staff assistance while in her wheelchair going up and down hills or maneuvering on uneven terrain and that Client 1 should be monitored closely by staff on outings as she is a risk for seizures. Facility document titled IPP (Individual Program Plan) Narrative dated 7/6/10 indicated that Client 1 lacks safety awareness and must always be supervised on outings. Under the title Bruises Easily indicated: "She is active in her wheelchair and not always aware of her surroundings, putting her at risk for bumps and bruises." Under the title of Mobility Risks indicated: "She is a risk for fractures due to Osteoporosis." Under the title of Supervision indicated: "She requires general supervision while on the unit. She requires close supervision while walking assisted and transferring. While on the grounds of the facility, she requires close supervision and when she is in the community, she requires constant supervision. She requires staff assistance while in her wheelchair, going down the ramp of her home unit, going up and down hills and on uneven terrain." Facility document titled Health Care Objectives and Plans dated 7/31/10 indicated: "She will have assistance necessary for all safe mobility." Under the title of Wheelchair indicated: "Footrests are to be used for transportation off unit. When not being pushed by staff on outings, should have her feet on the ground." On 2/2/11, at 11:30 a.m., Staff A was interviewed. Staff A stated that Client 1's footrests were to remain in the "up" position until staff could take control of her wheelchair. Staff A stated that there was no Accountability Log with supervision assigned during the outing. Staff A stated, "It was a group effort in supervising the clients." Staff A stated, "We should look at the environment at the campsite for making corrections." Staff A further stated, "As far as her footrest being in the "up" position, I really don't think that she could have stopped herself even if her feet were on the ground. She needs staff assistance on uneven terrain." On 2/8/11, at 1 p.m., Staff B was interviewed. Staff B stated that she had attended the outing with the clients and several other staff. Staff B stated that there were no specific assignments made for staff supervision of clients. Staff B stated, "She released her brakes and no one noticed until she started to roll down the hill. Someone yelled to catch her - and I attempted to stop her, however I could not help her. She rolled approximately 25 feet down the hill, the wheelchair flipped forward and onto its side rolling down the embankment." Facility policy number 460 Supervision of Clients under the title of Assessment of Supervision Needs, was reviewed on 2/8/11, at 2 p.m. "Close Supervision" indicated: staff must be in the immediate area and must be able to see and/or hear the client at all times, making visual contact no less than every 5 minutes." "Constant Supervision" indicated: "Staff must maintain constant visual and verbal contact with each client and is in close enough proximity to intervene as necessary." Facility policy number 543 Transportation Safety was reviewed on 2/8/11, at 2:30 p.m. Under the title of Waiting for Transportation indicated: "Residential and vocational support staff will be responsible for the safety and supervision of passengers who are waiting for transportation." The facility failed to comply with the above regulations by failing to keep Client 1 free from the potential harm by failing to follow Client 1's Mobility Plan, which indicates that Client 1 requires staff assistance while in her wheelchair for outdoor propelling in uneven terrain. Further, the facility failed to implement its' own policy to provide close supervision for Client 1 during an outdoor field trip. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150008629 |
A |
04-Jun-12 |
1YFO11 |
7337 |
42 CFR 483.420(a)(5) (W127) Protection of Clients RightsThe facility must ensure the rights of all clients. Therefore, the facility must ensure that clients are not subjected to physical, verbal, sexual or psychological abuse or punishment. The facility failed to ensure that clients were not subjected to physical or psychological abuse or punishment when 9 of 27 clients on the Judah Unit, 1 Client on Malone Unit and 1 Client on Lathrop were found to have abrasions consistent with the use of a Taser device. In addition, the facility failed to prevent further potential abuse when the staff member who was accused of abuse was not immediately removed from client contact following knowledge of the abuse complaint. The facility also failed to implement its policy prohibiting weapons from being brought onto facility grounds when the staff member accused of abuse was found with a loaded gun and Taser device on facility grounds.Facility documentation reviewed on 10/5/11 at 10 a.m., revealed that on 9/26/11 at approximately 4 p.m., an anonymous male caller left a message on the Executive Director?s answering machine. The anonymous caller alleged that Staff A, who worked on Judah in the Intermediate Care Facility for Developmentally Delayed Individuals (ICF/DD), had a stun gun and was using it on the clients.Review of the Office of Police Services (OPS) report indicated that officers went to the unit to make contact with Staff A on 9/26/11 at approximately 4:30 p.m., 30 minutes after receiving the anonymous call. Police were told that Staff A was not working at that time, but was scheduled to work the following morning, 9/27/11. The facility police investigation on 9/27/11 revealed that at 7:50 a.m., officers arrived at the client residence (Judah) to make contact with Staff A and were told that he was on break and would return shortly. The day shift began at 6:30 a.m. Officers were given a description of the vehicle Staff A was driving. A few minutes later the vehicle arrived in front of the residence where Staff A was returning after his break. The vehicle was searched with the consent of Staff A. The facility officer removed a black nylon handgun case from under the passenger seat. The case contained a Glock semi-automatic pistol and a ?magazine? containing live rounds of ammunition. The pistol was removed from the case and another magazine was secured in the receiver of the pistol that also contained live rounds. Upon searching the vehicle further a Taser C2 device was found in the driver?s side door storage compartment.Staff A had been working with clients for over one hour on 9/27/11 prior to being removed from client contact as per the facility?s abuse policy and procedures. According to facility documentation, Staff A was removed from client contact and placed on Administrative Time Off (ATO).On 10/5/11 review of the facility Abuse/Neglect Prevention and Reporting Policy 413 revised March 2009 indicated according to Section 4.3.1 that the Program Director shall: ?Immediately remove the alleged perpetrator from client contact? and notify the Clinical Director.Review of facility documentation on 10/5/11 regarding Staff A revealed that the staff had worked at the facility, as a Psychiatric Technician Assistant (PTA) since 1995. The facility job description for a PTA included the following: the provision of general nursing care and training for clients, assists clients in all activities of daily living such as bathing, dressing, grooming and dining, on-going interaction with clients, participates as a member of the Interdisciplinary team in designated aspects of the development and implementation of the Individual Program Plan, and the performance of nursing procedures consistent with Certified Nursing Assistant (CNA) regulations. A PTA?s assignment usually involved supervision of a group of 6-12 clients depending on the time of day or an assignment of one client i.e., providing constant or close supervision to protect the client from himself, from others or to protect others from the client.On 9/27/11, a day after the anonymous complaint that Staff A was using a Taser stun gun on clients residing on the Judah unit, registered nurses physically assessed all 27 clients on Judah for possible injury. Photographs of seven clients showed atypical appearing abrasions. The majority of these marks were found on the buttock, thigh, arm and back areas of clients. On 9/28/11 photographs were taken by the Office of Police Services (OPS) and were reviewed by a private forensic pathologist consultant.The forensic pathologist?s report dated 10/4/11 indicated that each injury was characterized by a pair of circular lesions ranging from 2-4 mm, some with small irregular central crater and others appearing as early scars, separated by 10 to 12 mm. The injuries of the seven clients were consistent with having been made by a very similar, if not identical device or weapon or instrument.The pathologist further opined that the patterned injuries on seven clients were strongly suggestive of and consistent with electrical thermal burns ranging in age of 36 to 48 hours up to greater than two weeks. The patterned (paired electrical-thermal) injuries were inflicted by another individual(s) on to these seven clients and represented non-accidental trauma. The report concluded that the features of the injuries could not be specifically attributed to the recovered electronic control device (ECD) Taser C2 and test ?firing? of this device onto skin-like material with varying durations of contact may be useful in determining the expected spread of the injury components.During an interview on 2/22/12, the forensic pathologist consultant stated that she was not as familiar with the C2 Taser as she was with the Taser used by Police Departments, and that marks from thermal injuries do not always match exactly the source of the marks. Ten of the eleven clients identified with electrical thermal injuries had limited or no ability to communicate verbally. According to the police investigation, Client 1 used the words ?stun? and ?[Staff A?s name]? during a recorded audio interview on 9/28/11.Review of the Individual Program Plan dated 3/2/11 described the communication ability of Client 1 as able to carry on a conversation, with ritualized social interactions and compulsivity that could interfere. The client was also described as able to verbalize his pain and his needs.Review of reported incidents for all 11 clients for the prior year failed to yield any relevant information. No witnesses or the anonymous caller came forward with any information regarding this allegation.In summary, the facility failed to ensure the right of all clients to be protected from abuse when: 11 clients were found with abrasions consistent with the use of an electrical thermal device (Taser Gun); the facility failed to implement the abuse prevention policy and immediately remove Staff A from client contact upon knowledge of the allegation; and Staff A was found with a loaded gun and Taser on facility grounds. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result potentially for all clients with whom Staff A had contact or whom had access to his vehicle. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150008724 |
B |
10-Apr-12 |
Q2JM11 |
6456 |
T22 DIV5 CH8 ART-3 76301(e) Required Services Client care provided by all team members shall be safe and considerate as ordered or indicated by the needs of the client and in accordance with acceptable standards of practice. The facility violated the above regulation when the facility failed to provide care that was safe and in accordance with acceptable standards of practice. A licensed staff member used excessive force and a potentially dangerous head and neck hold to physically restrain a client during a medical procedure, as follows; Client 1's clinical record reflected an Individual Program Plan (IPP) dated 11/9/10 documented Client 1 had diagnoses including mental retardation, autism spectrum disorder, and organic mood disorder. The IPP indicated Client 1 was believed to hear and understand everything that was said to him. Client 1 was fearful of rooms with bathtubs. Prior to admission, attempts to take Client 1 for medical and dental care were unsuccessful due to his behaviors. The IPP documented Client 1 complied better with female staff than male. Notes of an Interdisciplinary Team (IDT) meeting dated 5/1/11 documented Client 1 had a new medical diagnosis of cancer. Treatment plans included chemotherapy. A review of Interdisciplinary Notes (IDNS) of 6/2/11 documented successful completion of five chemotherapy treatments at an acute care hospital. The chemotherapy was given through a vascular access port which was implanted in the right subclavian artery.IDN dated 6/3/11 documented Client 1 received chemotherapy at an oncology center and was combative during the procedure. Notes indicated treatment was only accomplished with staff assistance. An incident report dated 6/9/11 indicated nurses at the oncology center called the facility to report Client 1 was, "held down strongly", "put in a headlock", and not spoken to by an escorting facility staff member. The nurses felt the experience was "abusive" and there was a "lack of professionalism, sensitivity and respect" during the procedure. During an interview on 9/29/11, a Registered Nurse (RN) employed by the oncology center stated Client 1 arrived for his first chemotherapy treatment at the site on 6/3/11. The RN stated she planned to first use the access port to obtain blood for laboratory studies. After the physician reviewed the blood tests results, she would administer chemotherapy through the port. The RN stated two facility staff members were in attendance, licensed Staff A and licensed Staff B. The RN stated Client 1 was seated in a wheelchair and became agitated as staff wheeled him into the treatment room. Staff A stated she spoke softly to Client 1 to explain the procedure of the blood draw. The RN stated Staff B held Client 1's right arm and right leg as she prepared to start the procedure of the blood draw. Staff B spoke softly to Client 1. The RN stated Staff A stated in Client 1's presence, "He (Client 1) will hit you. He will bite you." The RN stated Staff A was asking how long the procedure would take and said, "Make it quick. I can't hold him for long." The RN stated Staff A used his left arm to hold Client 1's left arm. Staff A wrapped his right arm around Client 1's neck and "cranked" Client 1's head way to the left. The RN stated Staff A's bent elbow was pressed against the underside of Client 1's neck and Client 1 was resisting vocally and physically. The RN stated the hold was, "very intense" and she heard Client 1's teeth grinding together. After the blood was drawn and the studies completed Staff A reapplied the same hold for approximately three minutes while the RN administered the chemotherapy through the access port. The RN stated Client 1 had not attempted to bite or spit. The RN stated she was upset by the experience and reported it to her supervisor. During an interview on 10/18/11, Staff A stated he had accompanied Client 1 on his trips to chemotherapy at the acute care hospital. Staff A stated there were signed informed consents for medical restraints to be used when Client 1 had procedures. During the chemotherapy treatments at the acute care hospital, Client 1 was placed in a bed. If physical containment was necessary staff could easily hold the arms and legs. Staff A stated the initial chemotherapy treatments took hours and there were times when he had to position the palm of his hand on Client 1's forehead and apply pressure to keep Client 1 still during the procedures at the hospital. Staff A stated Client 1 enjoyed treatment in the hospital because he had his own room with his own TV and remote. Staff A stated there was only an exam table in the room at the Oncology Center. Someone gave Client 1 a remote to hold, but there was no TV to go with it. Client 1 was in a simple transfer wheelchair with no headrest. Staff A demonstrated how he used his right arm to turn Client 1's head to the left away from the access port during the procedure. Staff A admitted he was never trained to physically contain a client in that manner. The application of pressure to the head and neck as Staff A was doing can cause unconsciousness and injury. ("... unconsciousness from a vascular neck restraint is caused by a compounding effect of ... Carotid Occlusion, ... Carotid Sinus/Vagal Stimulation, ... Venous Compression, ... (and) Valsalva ... Susceptibility ... Dislocation, fracture, and/or spinal cord injury can result from excessive force ... formation of a thrombus ... can result in a stroke ... cardiac arrhythmia ... can be triggered ..." www.personalprotectionsystems.ca/Safety_Articles/Neck ... Restraints) During an interview on 10/7/11, the facility instructor for Management of Assaultive Behavior (MAB) stated more than two staff members would be necessary to safely physically restrain a client in a wheelchair. The instructor stated facility staff members are never taught to use any type of head and neck holds. The instructor stated the staff members are taught to back away and re-assess the situation if a client cannot be safely restrained using the methods taught in MAB. Therefore the facility failed to ensure client care was safe as indicated by the needs of the client and in accordance with acceptable standards of practice. Staff A used excessive force to apply a potentially dangerous head and neck hold to Client 1. These facility failures had a direct or immediate relationship to the health, safety, or security of long term health care facility clients. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150008849 |
A |
12-Dec-12 |
J0DT11 |
8459 |
T22 DIV5 ART4-76525 (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. The facility failed to comply with the above regulation when it failed to ensure protection of clients from a violent peer. Client 1's aggressive behaviors toward other clients increased in intensity of violence without changes in plans or supervision, until Client 1 caused life-threatening injuries to Client 3, a medically fragile client. On 9/20/11, a review of an Individual Program Plan (IPP) dated 5/5/11, indicated Client 1 had mild mental retardation and intractable epilepsy. The IPP documented Client 1's ability to plan his behavior and his history of violence to peers with the potential for causing severe injuries to others. The IPP documented Client 1 required close supervision on the residence due to his seizures. The IPP indicated close supervision of Client 1 meant, "visual/verbal contact at least every five minutes ...". A review of a direct caregivers' guide entitled, "Windows" last revised 6/20/11 indicated, "(Client 1) continues to be monitored closely due to frequent seizures." On 9/23/11, a review of the facility document entitled, "Supervision of Clients" dated February 2011 indicated, "Close Supervision: Staff must be in the immediate area, hear the client at all times, and must make visual contact at least every 5 minutes." On 9/23/11, a review of Client 1's behavior plans revised 3/17/11 and 5/10/11, identified Client 1's assaultive behaviors but did not describe Client 1's level of supervision. The IPP, Windows, and behavior plans did not indicate Client 1 required increased supervision due to behaviors. On 9/23/11, a review of Client 3's special meeting notes dated 8/25/11, documented a summary of significant acts of aggression by Client 1 between Spring of 2010, and July of 2011, included, "...1) grabbing a female peer, placing her in a headlock, choking her and injuring her back; 2) forcefully pushing a peer and exhibiting threatening behavior toward staff; 3) elbowing a peer in the eye; 4) punching a peer in the face causing swollen lip, bruising and scratches to R eye; 5) striking a female peer on her head, face and trunk; 6) pushing a female peer into a wall resulting in a R ankle fracture; 7) punching a female peer in the face and abdomen resulting in a bruise to cheek; 8) kicking a female peer's right hip, slapping her forehead and hitting her back; 9) charging at a female peer threatening to choke her and assaulting staff who tried to intervene; 10) pushing female peer to the floor, grabbing her hair and attempting to hit her head against the floor ...".On 9/27/11, a review of an incident report dated 7/23/11, documented Client 1 chased Client 2 down the hall, knocked her down, grabbed her by the ears and banged her head on the floor. Client 2 sustained lacerations to both ears requiring six sutures to a deep gaping laceration behind the right ear.During an interview on 9/27/11 at 3:30 p.m., a licensed staff member, (Staff A) stated Client 1 had to be pulled off Client 2. Staff A stated Client 2's external ear was nearly separated from her head. Staff A stated Client 1 had been on close supervision and should have been placed on one-to-one (individual) supervision after the violent attack on Client 2. On 9/14/11, review of an incident report dated 7/25/11 at 3:30 p.m., (two days after Client 1 attacked Client 2) documented that Client 1 appeared at the nurses' station with blood on his arms and reported he had beaten Client 3. Staff members found Client 3's face down in a pool of blood. The report documented facial and nasal lacerations and bruising and a visible deformity of Client 3's nose as well as a full thickness laceration of the left ring finger consistent with a bite wound. On 9/14/11, a review of Client 3's interdisciplinary notes (IDNs) dated 7/25/11, indicated Client 1 had a history of sneaking into peers rooms and beating them up when he feels that individual has slighted him in some way. A review of Client 1's notes dated 7/25/11 at 6:20 p.m., indicated, "(Client 1) sneaked into (Client 3's) room and assaulted him as he was relaxing in his bed."On 11/4/11, a review of Client 3's clinical record reflected consultation reports from an acute care hospital dated 7/25/11, and documented Client 3 had a history of pulmonary embolism and was taking an anticoagulant medication. The reports documented Client 3 sustained a loss of sensorium (mental awareness), a broken nose, and multiple contusions (bruises) over his face. He was transferred to an acute care hospital where a head CT scan (Computed Tomography Scan) showed a traumatic subarachnoid hemorrhage (bleeding into the area between the brain and the thin tissues that cover the brain) and a right temporal hemorrhagic contusion (bleeding within the brain tissue). Client 3 was then transferred to the nearest trauma center for services. Client 3 also sustained multiple contusions over his forehead and a severe human bite on the left ring finger.A review of Client 3's case management notes dated 7/26/11, documented Client 3 had a clotting disorder which required lifelong anticoagulation. Notes of 7/27/11, documented Client 3 had stabilized in intensive care where he received services to prevent thrombosis after the need to reverse anticoagulation. Notes of 7/29/11 indicated Client 3 returned to the facility. On 11/4/11, a review of IDNs from 7/29/11 until 8/15/11 indicated Client 3 refused to eat most meals and isolated in his bed in his room most of the days. On 8/4/11 he was lying on the floor and stated, "I fell." On 8/5/11 Client 3 returned to the acute care hospital to have the nasal fracture reduced. On 8/7/11 he appeared unsteady and required assistance getting in and out of bed. On 8/8/11, the bite wound to the left ring finger was found to be wet and macerated. On 8/9/11 Client 3 refused to get up and walk around, exhibited episodes of anger, but was eating meals.On 9/27/11, a review of staffing records for 7/25/11, documented Staff A was in charge and Staff B was assigned to Family II. Both Clients 1 and 3 were in Family II. When Staff B left the residence to escort three other clients to the store at 3:15 p.m., Staff A was responsible to supervise the remaining Family II clients in addition to passing medications and performing other charge duties for the entire unit. During an interview on 9/27/11 at 3:30 p.m., Staff A stated she saw Client 1 close the double doors to the hallway and go into his room. Staff A stated staff members had been allowing Client 1 to close the double doors to his hallway because the noise around the nurses' station bothered him. Staff A stated Client 3 had been upset earlier in the day and was in his room calming down. Client 3's room was in the same hallway as Client 1's room. Staff A stated there was a hole in the staffing coverage and Client 1 sneaked into Client 3's room unseen by staff. On 9/27/11, a review of Client 1's Special Meeting notes of 8/25/11, documented, "Due to (Client 3's) existing health condition, this life-threatening incident could have resulted in tragedy ..." Therefore, the facility failed revise Client 1's program plans to ensure clients rights to be free from abuse after Client 1 exhibited a series of increasingly violent attacks on other clients. The facility failed to change program plans after Client 1 chased Client 2 down the hall, held Client 2 by the ears, and banged her head on the floor nearly separating Client 2's external ear from her head. Two days later, staff failed to provide the planned supervision to keep Client 1 within sight or hearing of staff at all times. When staff allowed Client 1 to shut the doors to his hallway, Client 1 was not within sight or hearing of staff. Client 1 sneaked into the room of Client 3 (a medically fragile client on blood thinners) and beat and bit Client 3 who sustained life-threatening injuries. 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. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150008930 |
B |
07-Mar-12 |
R5RF11 |
5233 |
T22 DIV5 CH8 ART3 76301(e) Client care provided by all team members shall be safe and considerate as ordered or indicated by the needs of the client and in accordance with acceptable standards of practice. T22 DIV5 CH8 ART4 76525(a)(20) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to comply with the above regulations when a client with a history of osteoporosis (bone loss disease) and multiple falls was not assessed after each fall and subsequently sustained a fractured arm after a fall on 11/27/11, as follows: According to the Individual Program Plan (IPP) for Client 1 dated 1/11/11 the client had the identified problems of gait abnormality, and risk for falls and fractures. The client's mobility was described as ambulatory and she used a four wheeled walker. She used a wheelchair when smoking to prevent falls due to possible lightheadedness and other times if unsteady or for community outings.Client 1 also had a history of impulse control and affect regulation difficulties. At this time the client's supervision level was close. Per SDC Policy 460 close supervision indicated that staff must be in the immediate area to hear the client at all times and must make visual contact at least every 5 minutes.On 3/23/11 at 11:20 a.m., Client 1 fell at her work site while walking into the bathroom and struck her head necessitating 5 stitches. The plan of care indicated that she could walk with or without her walker inside and preferred not to use it. Also that she should be encouraged to use it as necessary. The client's plan also indicated the use of a wheel chair for smoking outside due to increased fall risk. There were no changes recommended after this incident. Review of the Individual Program Plan dated 3/23/11 indicated that staff should remind Client 1 to ask for help, to look where she is going as she moves about. This information was not added to the plan of care. There was no evidence of a Fall Risk Assessment after this incident.On 5/25/11 facility documentation indicated that the client fell when maneuvering around a peer boarding the tram. She was in a hurry and not looking where she was going. She ignored or did not hear verbal prompts to slow down. She tripped and fell sustaining a scraped knee. The physical therapist assessed the walker as appropriate and stated they could not slow the wheels down. The recommendation was to have the HSS update the falls risk assessment and staff watch her and remind her to slow down, making sure she has paid attention noting that extra care needs to be taken when other peers are with her moving in a group. The plan of care was not updated to reflect this recommendation. There was no evidence of a Fall Risk Assessment.On 7/18/11 a Falls Risk Assessment was completed. A note on the document indicated that there was a fall due to water on the floor and no change was indicated.On 10/15/11 another Fall Risk Assessment was done and a handwritten entry indicated that the client "slipped out of bed onto floor no injury". On 11/20/11 a physician's note indicated that Client 1 fell on route to breakfast using her walker. Another fall risk assessment was completed with no apparent change in the plan of care. On 11/27/11 an Incident Report (IR) reflected that Client 1 fell while using her walker outside the residence. Although staff had requested that the client sit and wait while they retrieved the client's wheel chair, (as per the plan), the client got up and fell while using her walker on the ramp. According to the plan of care Client 1 used a wheel chair for smoking outside. Client 1 was diagnosed with a right arm fracture. At this time the client's supervision level was still "close".During observations, on 12/5/11 Client 1 was lying across her bed on her side looking at a magazine. A cord (telephone-like) was draped over her ankles. The client's room was cluttered with objects on the floor near the bed. With staff present the client walked down the hallway and back to her room using the walker. The client's shoes appeared large with space at the heel of the shoe; the client's gait was shuffled and quick with heels almost touching. Upon return to her room the client lost her balance almost falling. During a concurrent interview the U.S. stated that the cord was part of the resident's bed alarm and that her shoes were being evaluated currently. There was no name on the shoes she was wearing during the 12/05/11 observations.Review of the client's record on 12/5/11 failed to indicate that after each fall the recommendations of the team were documented on the plan of care to ensure client safety and on-going reassessment. In summary the facility failed to reassess Client 1 after each fall and revise the plan of care, to protect her from harm.This failure had a direct or immediate relationship to resident health, safety and security. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009262 |
A |
12-Dec-12 |
HQ9111 |
6817 |
T22 DIV5 CH8 ART3-76301(e) Required Services (e) Client care provided by all team members shall be safe and considerate as ordered or indicated by the needs of the client and in accordance with acceptable standards of practice.The facility violated the above regulation when it failed to ensure clients were safe from injury when Client 1 was biting others. After multiple incidents of hitting and biting staff and peers, Client 1 was placed on individual (one-to-one) supervision prior to an administrative transfer to a different unit. Seven days after the transfer, staff discontinued the individual supervision without a team assessment. Client 1 began to bite peers and continued to bite peers until the team conducted an assessment and increased supervision twenty days later as follows: On 11/16/11, a review of an incident report dated 9/12/11 indicated Client 1 ran down the hall and bit Client 2, who was in a wheelchair. Client 2 sustained a bite mark on the left upper arm with bruising, abrasions, and tooth marks. On 11/16/11, Client 1's clinical record was reviewed. A review of Client 1's interdisciplinary notes (IDNs) dated 9/12/11 at 12:25 p.m. indicated Client 1 hit a peer while at day program. IDNs, at 2:40 p.m., indicated Client 1 bit Client 2 after returning to the unit from day program. The IDNs indicated staff provided 1:1 (individual) supervision for Client 1 until the psychologist came to evaluate him. IDNs at 3 p.m., indicated the psychologist recommended constant supervision (staff close enough to intervene if necessary). Notes of 9/12/11 at 9 p.m., indicated Client 1 was placed on close supervision (staff in the area with eye contact every 5 minutes) at 8 p.m., and was back on general supervision at 9 p.m. On 11/16/11, a review of the facility document entitled, "SUPERVISION OF CLIENTS" dated February 2011 indicated, "General Supervision: Staff must make visual and/or verbal contact with each assigned client no less than every 15 minutes ... Close Supervision: Staff must be in the immediate area, hear the client at all times, and must make visual contact at least every 5 minutes ... Constant Supervision: Staff must be able to see and/or hear each client and be in close enough proximity to intervene as necessary ... One-to-One (1:1) Supervision ... Staff must be able to see their assigned client at all times and be in close enough proximity to protect them and others from injury ... Staff must not leave client unattended at any time or be distracted by other issues." A review of IDNs of 9/13/11 at 2:40 p.m., documented Client 1 bit Client 3 on the back while at day program. Staff provided 1:1 supervision after the incident. A review of IDNs of 9/13/11 at 3:47 p.m., documented the use of sedatives for Client 1 due to extreme agitation. IDNs of 9/14/11, documented Client 1 hit a peer while at the worksite and then hit another peer before a 1:1 staff member could intervene. IDNs of 9/16/11 at 8:30 a.m., documented Client 1 bit Client 4. Client 4 sustained a bleeding circular wound on the right forearm. A review of IDNs dated 9/16/11, documented Client 1 hit a staff member several times. IDNs of 9/26/11 at 6 p.m., indicated Client 1 reached out and bit a staff member on the shoulder while on 1:1 supervision. Client 1 hit the psychologist who came to assist. IDNs of 9/27/11 at 10:30 a.m., indicated Client 1 bit a staff member. A review of Client 1's clinical record reflected an annual Individual Program Plan (IPP) dated 10/14/11, which documented Client 1 had diagnoses including severe mental retardation, autism, intermittent explosive disorder, and bipolar disorder. The record showed that Client 1 was hospitalized for multiple surgeries in 2010. The IPP documented Client 1 was having episodes of severe agitation and bit staff in May of 2011. Physicians had adjusted Client 1's behavioral medications multiple times. Client 1's IPP of 10/14/11, documented Client 1 was on 1:1 individual supervision. A review of IDNs of 10/18/11, documented Client 1 was transferred to another unit of the facility due to closure of his home unit. During an interview on 11/16/11 at 3 p.m., the Unit Supervisor (US) stated Client 1's 1:1 (individual) supervision had been discontinued on 10/25/11. The US stated she was new to the unit and did not know why Client 1 was taken off individual supervision and put on general supervision seven days after the transfer. On 4/3/12, the clinical records of Clients 5, 6, and 7 were reviewed. A review of Client 5's IDNs dated 10/25/11 at 5:10 p.m., indicated Client 1 was seen with his mouth on Client 5's right shoulder. Staff discovered a human bite wound with bruising, teeth indentations, and abrasions on Client 5's right shoulder. A review of Client 6's IDNs dated 10/25/11 at 5:50 p.m., indicated staff observed Client 1 was in the area just before staff discovered Client 6 had a bite mark with redness and some peeled back skin present in multiple areas. During the interview on 11/16/11 at 3 p.m., the US could not explain why supervision was not increased after Client 1 bit two peers the evening of 10/25/11, just hours after 1:1 supervision was discontinued. A review of Client 7's IDNs dated 10/30/11 at 6 p.m., indicated staff discovered a bite wound on Client 7's left back with abrasions, swelling and discomfort to touch. Client 7 was Client 1's roommate. A review of Client 5's IDNs dated 11/8/11, indicated staff discovered an abrasion on his right shoulder. The assessment of the injury indicated it could possibly be a bite attempt by a peer. Client 1's IDNs of 11/12/11 at 2 p.m., indicated staff observed Client 1 bite Client 5 on the left bicep. Client 5's IDNs for that time indicated Client 1 bit Client 5 before staff could redirect Client 5 away from Client 1. A review of Client 1's Special Team Meeting notes dated 11/14/11, indicated Client 1's level of supervision had been "general" during the twenty days since 10/25/11. The notes did not reflect discussion of the reason Client 1 was taken off 1:1 supervision and put on general supervision seven days after he was transferred to a new unit. Notes documented Client 1 subsequently inflicted bites on four occasions, with one peer sustaining two bites. The meeting notes documented the interdisciplinary team's decision to increase Client 1's level of supervision on 11/14/11. Therefore the facility failed to ensure safety of clients when Client 1's individual supervision was discontinued without a team assessment. Client 1 inflicted four bites on three peers before increased supervision was resumed twenty days later. The above violations presented either imminent danger that death or serious harm would result or a substantial harm would result or a substantial probability that death or serious physical harm would result. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009314 |
A |
12-Dec-12 |
CQ3J11 |
4049 |
T22DIV5CH8ART3 76301(e) Required Services (e) Client care provided by all team members shall be safe and considerate as ordered or indicated by the needs of the client and in accordance with acceptable standards of practice.The facility violated the above regulation when it failed to provide the safe diet as ordered. Client 1 had difficulty swallowing and choked on pizza after staff failed to ensure all his food was chopped and his bread was soaked as follows: On 3/12/12, a review of an incident report dated 10/29/11 at 12:10 p.m. indicated Client 1 was sitting next to his relatives during a family pizza party when he began choking. The report indicated Client 1 was at high risk of choking because of missing teeth. The report indicated a staff member applied abdominal thrusts (a thrust that creates and artificial cough forceful enough to clear the airway) and the food was dislodged. The code team arrived and assessed Client 1 who did not have complications from the incident. On 4/10/12 at 2 p.m., Client 1's clinical record was reviewed. A review of Client 1's interdisciplinary notes reflected notes of 10/29/11 at 12:12 p.m., "While eating lunch at Parent Party, (Client 1) began to choke on pizza. His sister yelled for help and staff immediately assisted. (Client 1) was starting to become pale and limp as staff gave multiple abdominal thrusts to dislodge food item ... " A review of Client 1's clinical reflected an individual program plan (IPP) dated 12/7/10 identified Client 1's swallowing problems and high risk for choking. Plans included a chopped textured diet, with moistened and cubed bread and with no tough chewy foods. He dined independently with supervision at the dining table. A health care plan for dining included written interventions implemented on 1/23/09 which indicated, "Diet consistency Chopped diet, cubed bread are (sic) moistened Thin fluids Avoid tough, chewy foods ... Cut into bite size pieces if food is prepared otherwise ... remind (Client 1) to eat slowly; and to eat small bites ..." During an interview on 5/7/12 at 2 p.m., Client 1's mother stated Client 1 has had difficulty swallowing since childhood. The mother stated she served Client 1 little pieces of food during home visits. At home, she cut his toast into little squares and soaked them with milk. The mother stated she usually arrived at the facility's family party in time to fix Client 1's plate for him, but that day traffic was heavy and she arrived a little late. Client 1 had already been served several oblong pieces of pizza about 4 inches long and 2 inches wide. The pizza was not bite sized, it was not chopped and the bread was not soaked. The mother stated Client 1 took one bite and became very red faced. The mother stated she was very upset by the experience. On 5/5/12, a review of a "MEDICAL EMERGENCY REPORT", dated 10/29/11 at 12:15 p.m., indicated a staff member intervened and dislodged the pizza piece after application of over twenty abdominal thrusts. During an interview on 5/7/12 at 2 p.m., Client 1's sister stated staff gave Client 1 a whole piece of pizza. By the time she and her mother arrived, Client 1 had been served and had already picked up a piece of pizza. The sister stated she noticed Client 1 turned red, his eyes were watering and he was drooling. The sister stated she started screaming, "He's choking" and everybody came running. A staff member, Staff A, worked vigorously and finally dislodged a gummy piece of pizza crust about the size of a quarter. Therefore the facility failed to ensure implementation of physician's orders for a chopped diet with soaked bread for Client 1 who had swallowing difficulties since childhood. Facility staff served Client 1 and intact piece of pizza and Client 1's airway became obstructed after one bite. More that twenty abdominal thrusts were necessary to dislodge the food bolus. 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. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009315 |
B |
03-Feb-14 |
0PL811 |
2492 |
T 22 DIV 5 CH 8 ART 3 - 76301e REQUIRED SERVICES (e) Client care provided by all team members shall be safe and considerate as ordered or indicated by the needs of the client and in accordance with acceptable standards of practice. The facility failed to provide safety for a client, Client 1, by failing to ensure maintenance of a safe worksite environment.A client with a long history of breaking windows "punched" a cubicle window at the day program and sustained "severe lacerations" to his left hand requiring surgical repair at the acute care hospital.Record review on 4/16/12 indicated that Client 1 had diagnoses that included IED (Intermittent Explosive Disorder). Client 1 had behavior plans for property destruction that included hitting and breaking windows and plans for self injurious behaviors that included hitting windows / hard surfaces with injuries to his hand. The facility IR (Incident Report), signed on 3/28/12, indicated on 3/28/12 at 10:30 a.m., Client 1 was sitting in a quiet area away from his peers when he began hitting the table.Staff immediately intervened and attempted to refocus him as he lifted a chair above his head to throw. He then quickly turned and struck the window with his left hand. The IR indicated that Client 1 had a long history of property destruction with the focus on breaking windows. Physician's Progress Notes, dated 3/28/12, indicated that Client 1 sustained "severe lacerations" to his left hand. Documentation from the Emergency Department indicated that Client 1 underwenta "complicated repair" for full thickness lacerations to the left index, middle, and ring fingers. During an observation of the worksite on 4/20/12 at 9 a.m., the cubicle where the incident occurred was separated from an adjoining cubicle by large glass windows with wire type reinforcement in the glass. During an interview with Site Staff A on 4/23/12 at 2:15 p.m., Staff A stated that Client 1 was all alone in a cubicle when he got up and started banging on the table. Staff A stated that she walked into the cubicle and he picked up a chair. Staff A was standing in front of him and grabbed a leg of the chair. Client 1 then proceeded to hit the glass. Staff A stated, "I was standing right there. It went through so quickly." The facility failed to maintain a safe worksite environment for a client with a known history of hitting and breaking windows.These failures had a direct or immediate relationship to the health, safety, or security of patients. |
| 150000229 |
SONOMA DEVELOPMENTAL CENTER D/P SNF |
150009318 |
B |
11-Feb-14 |
FRIR11 |
7815 |
T22 DIV5 CH3 ART 3 - 72311 (a) (1) (A) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. T22 DIV5 CH3 ART5 - 72523(a) Patient Care Policies and Procedures Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.The facility failed to ensure facility protocols and Administrative Directives were implemented. A resident with a prior elopement history independently exited the unit in his wheelchair without staff supervision. The resident was found face down outside on the grass while still strapped into his wheelchair and had sustained a nose bleed and a scratch to his forehead. Staff moved the resident indoors before he was assessed as safe to be moved by appropriate medical staff. The facility also failed to ensure that the assessment of the resident's supervision level was consistently documented in the record.Review of the facility's Unusual Occurrence Report, signed on 1/16/12, indicated that on 1/16/12 at 9:15 a.m., kitchen staff reported to unit staff that they observed a resident's wheelchair had tipped over with the seatbelt and lap tray intact. The resident was positioned face forward.As indicated in the Office of Protective Service's report, the lap tray was still attached.Further documentation in the Unusual Occurrence Report indicated that it appeared upon finishing breakfast, Resident 1 propelled himself toward the front door, out of the unit, and out of the front door of the building where his wheelchair's front wheels rolled off of the sidewalk and onto the grass propelling him forward. Staff assisted the resident and the wheelchair was put in the upright position. Resident 1 was assisted back to the unit where first aid was administered for a bloody nose and a scratch on his forehead.The Unusual Occurrence Report indicated that this was the second incident where the resident had eloped from the residence without staff assistance during the past year. The prior incident occurred on 1/3/11.Review of the IPP (Individual Program Plan), dated 9/28/11, indicated that Resident 1 was non-ambulatory and used a customized wheelchair for mobility, which he self-propelled with his feet.Physician's Progress Notes, dated 1/16/12 at 9:30 a.m., indicated the resident was possibly out of the unit for 15-20 minutes.Subsequent to the 1/3/11 elopement, a review of the IPP, dated 2/7/11, indicated the following: Team determined for Resident 1's safety and protection, his supervision level should be modified to "constant" (staff must be able to see and /or hear each client and be in close enough proximity to intervene as necessary) when he is in the living room in his wheelchair and "general" (visual and/or verbal contact no less than every 15 minutes) while he is in the living room in the lounge chair. He will continue to receive general supervision while in other areas of the residence, including the backyard.The Administrative Directive for "Supervision of Clients," (#460, effective 1/12), included the following definitions: General Supervision- Staff must make visual and / or verbal contact with each assigned client no less than every 15 minutes. Constant supervision- Staff must be able to see and/or hear each client and be in close enough proximity to intervene as necessary.Close Supervision- Staff must be in the immediate area and must make visual contact at least every 5 minutes. Despite having one staff present in the living room at the time of the current incident, as indicated in the Unusual Occurrence Report, Resident 1 was able to exit the unit unsupervised through the front door. A subsequent IPP, dated 9/28/11, indicated Resident 1's level of supervision was "general" supervision in familiar indoor environments and "close" supervision in unfamiliar environments and on outings, as he did not have hazard awareness. There was no reference made to the enhanced supervision that was put in place during the above mentioned 2/7/11 IPP that indicated "constant" supervision when Resident 1 was in his wheelchair in the living room nor was there any documentation that the resident was reassessed to reduce / downgrade his supervision as indicated in the 9/28/11 IPP.Additionally, the "windows/cue card" document (a document given to staff listing a variety of aspects of care i.e., diet, behaviors, risks, supervision levels, etc.) indicated that Resident 1 was on "close" observation.Documentation of supervision levels in the 2/7/11 IPP, 9/28/11 IPP, and the "windows" document was inconsistent. Clarification regarding Resident 1's level of supervision, at the time of the incident, was requested by the surveyor. The Unit Supervisor, Staff A, stated that Resident 1 was on "close" supervision and the entry in the 2/7/11 IPP for "constant" supervision was a "typo."On 2/7/12 at 2 p.m., during an interview with the MDS/IPC (Minimum Data Set / Individual Program Coordinator), the Coordinator stated that the supervision levels were probably not updated with the 9/28/11 IPP. The MDS/IPC acknowledged that there were inconsistencies in the documentation of Resident 1's supervision levels. During an interview with Staff B on 2/10/12 at 11:15 a.m., Staff B stated that she was the Group Leader in charge of 4 to 5 residents, including Resident 1. Staff B stated that she had finished feeding another resident in Dining Room 1, brought the food cart to the kitchen, and then helped to feed a resident in Dining Room 2, as they were behind with feedings. Staff B further stated that another staff, Staff C, was feeding Resident 1 in Dining Room 1.Staff B stated that she was unaware that Resident 1 had finished eating in Dining Room 1 as there was no communication from Staff C that he had completed his meal.During an interview with Staff C on 2/28/12 at 1:45 p.m., Staff C stated that she could not recall if she fed Resident 1 but did remember seeing him in the hallway at 9 a.m. Staff C stated, "We had to watch him."The policy for "Falls Prevention, Assessment and Care Cervical Spine Precautions" (P 901, reviewed 9/11) included the following: "Unless the client is in immediate danger, do not move the client and summon medical/nursing assistance immediately by calling MD/FNP (physician / family nurse practitioner) and HSS/ACNS (Health Services Specialist/ Assistant Coordinator of Nursing Services).In an emergency, dial "3" for Medical Emergency team response."During an interview with Staff A on 2/7/12 at 1:30 p.m., staff acknowledged that the resident was moved before he was assessed.During a telephone interview with Staff D on 2/7/12 at 1:45 p.m. Staff D stated that four staff went to assist the resident. Resident 1 was face forward with the side of his face leaning to the right side. Staff D stated, we were slowly getting him upright, "I was trying to get him air." He stated he was awake and alert and was brought back to the unit where he was assessed. The facility failed to ensure assessment of supervision levels was consistently documented to ensure staff implemented supervision as intended for a resident with a known elopement history. The facility failed to ensure a resident, with a potential neck injury, was not moved prior to appropriate medical assessment.These failures had a direct or immediate relationship to the health, safety, or security of patients. |
| 150000229 |
SONOMA DEVELOPMENTAL CENTER D/P SNF |
150009431 |
A |
22-Jul-13 |
173S11 |
11339 |
F224 483.13 (c) PROHIBIT MISTREATMENT/NEGLECT/MISAPPROPRIATION The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to implement the Abuse and Neglect Prevention Policy #413 when a totally dependent disabled resident (Resident 1) with a history of pica, (craving for or ingestion of a non-edible item) ingested a large amount of cloth material. Four days after the ingestion, the resident was admitted to a community acute care hospital for decreased level of consciousness, vomiting coffee ground liquid with pieces of cloth, and change in vital signs. Resident 1 died four days after hospitalization of Acute Respiratory Distress Syndrome. Review of the record indicated that Resident 1 was a 68 year old admitted to the facility in 1947 with a long history of pica. The resident was non-verbal, non-ambulatory and totally dependent on staff for all activities of daily living, except eating. The resident was able to use her right upper extremity to grasp objects and to feed herself with limited assistance of staff, according to the most recent Minimum Data Set (MDS) dated 9/2/11. Review of the facility incident report indicated that on 11/22/11 at approximately 3:10 p.m., Staff A, a psychiatric technician assistant (PTA) found Resident 1 in bed ingesting a tee shirt she was wearing. Resident 1's plan of care for pica dated 4/5/11 indicated that the resident was to wear special clothing made of non-tear material at all times and a long gown made of non-tear material when in bed. Blankets and pillow cases were also to be made of non-tear material. The Medication and Treatment Record (MTR) noted: "Pica Alert; Special night-gown/PJ's (pajamas) to be worn at HS (hour of sleep) no exceptions (in bold ink) Bed sheets and blanket also)" and "offer bed rest 2 hours in the afternoon." According to the unit's 24 hour report log, Licensed Staff E was in charge on the day of the incident. During an interview on 1/19/12 Staff E stated that Staff G was assigned to the resident and had worked with her a long time and knew her plan well. Staff E stated that he had helped this staff with her assignment that day.The facility Office of Protective Services (OPS) report indicated that during their interview on 12/9/11, Staff E stated that he "dressed Resident 1 that day... he indicated it was after lunch nap time."During an interview on 1/20/12 at 11 a.m., Licensed Staff F stated that at times staff would dress the resident in normal clothing however only when she was up in the wheelchair and under constant supervision.During an interview on 1/24/12 at 10:30 a.m., Staff D stated that "everyone knew her plan of care."During an interview on 12/6/11 at 3:40 p.m. the police investigator who was assigned the investigation on 12/6/11 showed a photo taken on 12/2/11 of a sign posted over the resident's bed. It read: "Pica Alert: Supplex (non-tear) long night shirt while in bed at all times. Make sure client is covered up with Supplex blanket...History of eating attends (adult diapers)...No neckerchiefs..."During an interview on 1/24/12 at 2:30 p.m., Staff A stated that when she usually began her shift at 2:30 p.m. she would find Resident 1 in bed in appropriate pica clothing. Staff would then dress, and transfer the resident to her wheelchair. However, on 11/22/11, the day of the pica incident, Staff A stated that Resident 1 was not wearing a non-tear gown as was usual. Staff A stated that Resident 1 had in her mouth cloth which she had grasped from underneath another shirt that was made of the appropriate non-tear material; a green V-neck shirt, and green pants. Staff A immediately removed the inappropriate clothing and showed the ripped tee shirt to the Unit Supervisor. Staff A stated that there were no pieces of material found in the bed or bed area. The Unit Supervisor reported to the resident's physician, (Physician A) as per the following Interdisciplinary Note (IDN) dated 11/22/11 at 3:20 p.m., "4 cm (centimeter) possible ingestion bottom of the shirt missing, history of Pica, MD notified ..."During an interview on 01/26/12 at 11:15 a.m., Physician A stated that she had been notified on 11/22/11 that the resident had a pica incident and was found with material in her mouth. The physician stated that she had been informed that the material had been removed and vital signs were stable. Physician A stated she therefore did not deem it was necessary to assess the resident in person at that time.The record indicated that Resident 1 showed no unusual signs until 11/26/11, when IDN's indicated that at 8:30 a.m., the resident passed stool with evidence of material in it. Then at noon she refused lunch. During an interview on 1/24/12 at 4 p.m., Staff A stated that Resident 1 always ate 100% of her meal. At approximately 4 p.m. on 11/26/11, a licensed nursing note described that the resident then had an emesis, was sleepy in appearance and had diminished breath sounds. The Medical Officer of the Day (MOD), Physician B, was notified and gave verbal orders to monitor the resident's vital signs every 4 hours, push fluids as tolerated and check blood sugar. The resident then refused dinner and at approximately 6 p.m., had another emesis with strips of material in it. The Psychiatric Technician Staff B notified Physician B again. During an interview on 1/25/12 at 3:15 p.m., Staff B stated that Physician B seemed annoyed and stated that he already was aware of the vomiting. Staff B stated she emphasized to the physician the presence of material in this episode of emesis. The physician did not come to the unit to assess the resident.At 12 midnight (2400) on 11/26/11, an IDN reflected that the resident again had emesis with another strip of material estimated at "approximately 5 inches in length by 1/2 inch and that the resident was "not [her] usual self. This was not reported to the HSS until 2:30 a.m., when Resident 1 had another emesis.On 11/27/11 at 2:30 a.m., Staff C, a Registered Nurse notified Physician B that the resident had another emesis with material in it at midnight and an emesis at 2:30 a.m., of dark brown liquid with an elevated pulse and respiratory rate. The physician did not assess the resident in person.During an interview on 1/26/12 at 10 a.m., Staff C stated: "I was trying to get him (Physician B) to understand that she was less responsive, her color was different even though her vital signs seemed stable." He responded that he thought she (Resident 1) would be just fine and asked if the resident had been given an antacid and was taking fluids. According to Staff C, Physician B then commented that the resident just needed to rest. Staff C stated that she then asked if the physician wanted to be called, if the resident had another emesis and he stated yes. On 11/27/11 at 5:35 a.m., Resident 1's IDN's reflected that Staff C notified Physician B that Resident 1 had another emesis, dark brown in color, a temperature of 99.2 degrees Farenheit and a pulse rate of 112. The physician gave orders to transfer the resident to the acute care hospital on facility grounds.Resident 1 arrived at the on grounds acute care hospital at 6:10 a.m., per the acute care hospital IDN, Resident 1 was unresponsive with a blood pressure of 105/70, pulse of 111. At 7:10 a.m., the resident was minimally responsive, pale and had a large coffee ground emesis with bits of material. The resident was then transferred to the community acute care hospital by ambulance.The nurse's record at the community hospital emergency department dated 11/27/11 at 7:30 a.m., described Resident 1 as, lethargic with an altered level of consciousness and vomiting black thick emesis. A stomach tube was inserted at 7:45 a.m. The nurse's record indicated that at 8:55 a.m., the resident continued to vomit despite the tube inserted to drain the stomach. The record indicated that at 9:15 a.m., the resident's vital signs changed drastically when it was noted that the resident's respiratory rate was in the 20's, with bilateral coarse breath sounds and oxygen saturation in the 70's indicating respiratory difficulty. The resident was emergently intubated (breathing tube placed into the airway) at 9:36 a.m.The death summary from the community hospital dated 12/2/11 indicated that "the resident was admitted to the intensive care unit in critical condition after large amounts of hematemesis (blood in vomit) and obvious aspiration (inhaling fluid or particulate matter into the lungs) both prior to arrival and in the emergency department as well as in the emergency department while being intubated." The death summary also indicated that the resident died on 12/1/11 at 9:45 p.m., of Acute Respiratory Distress Syndrome (ARDS), Aspiration Syndrome and Hematemesis. An Esophagogastroduodenoscopy (EGD) was performed at the hospital on 11/30/11. [EGD is a test that examines the lining of the esophagus (the tube that connects the mouth to the stomach), stomach, and first part of the small intestine. It is done with a small camera (flexible endoscope) that is inserted down the throat. Medlineplus at nih.gov] The EGD "revealed a large amount of cloth material in the stomach, unable to be removed due to its breakdown from stomach acid. No ulcerations or gastritis noted."A photograph of the ripped shirt taken by OPS (Office of Protective Services) on 12/2/11 reflected measurements of approximately 15 cm by 13 cm of missing cloth from the shirt. (color photo of resident's blouse with missing measured area). The facility policy titled, "Abuse/Mistreatment/Neglect Prevention & Reporting" #413 effective March 2009, stated that "Abuse, mistreatment, or neglect of any person living at Sonoma Developmental Center (SDC) is strictly prohibited." The policy defined neglect as "Any willful act or lack of action that causes or may cause harm which may include but is not limited to failure to provide medical care, mental health needs, assistance with personal hygiene, adequate clothing and nutrition, protection from health and safety hazards, required habilitation and training services, or sleeping while on duty." In summary, the facility failed to: implement the Abuse and Neglect prevention policy #401 when the facility failed to protect Resident 1, who had a known history of pica, from neglect by not preventing her from wearing and ingesting an article of regular clothing which her plan of care stated she was not to wear due to risk of pica. The facility also failed to ensure the prompt assessment by a physician when: the initial report to the resident's physician indicated a smaller amount of ingested material than was actually missing and four days after ingestion the covering physician was notified repeatedly of the resident's signs of refusal to eat, vomiting and material noted in the emesis for 12 hours did not go to the unit to assess Resident 1. These failures led to a delay in appropriate treatment for this high risk non-verbal, dependent, resident with recent ingestion of a large amount of clothing material.The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result for Resident 1. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009497 |
A |
12-Dec-12 |
HJ6711 |
8197 |
T22 DIV 5 ART4 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.The facility failed to prevent neglect by failing to implement policies and procedures (P&P) related to pica (persistent ingestion of nonnutritive substances) for 2 clients (Clients 1, 2): 1. Client 1 ingested gloves and other items requiring surgery to remove the items from his stomach and subsequently obtained pieces of a wooden bed frame while on individual supervision; 2. Client 2 required emergency surgery after ingesting sunglasses, despite a long history of attempting to ingest them. A review of the facility's Administrative Directive titled, "Abuse /Mistreatment/ Neglect Prevention & Reporting," effective 3/09, included the following definition of neglect: Any willful act or lack of action that causes or may cause harm which may include but is not limited to failure to provide medical care, mental health needs, assistance with personal hygiene, adequate clothing and nutrition, protection from health and safety hazards, required habilitation and training services, or sleeping while on duty. A review of the facility policy and procedure (P&P) titled, "PICA," (sic) dated December 2011, indicated, "Pica is the persistent ingestion of nonnutritive substances including, but not limited to: clay, dirt, sand, stones, hair, feces, lead, gloves, plastic, paper, paint chips, wood, string, cloth, metal, and /or cigarette butts...All clients assessed by the unit Psychologist to have a PICA (sic) condition shall have a Behavior Plan and a Health Care Plan and Objective to address prevention strategies and intervention requirements." The P&P indicated that the purpose was "To protect clients from harm related to the ingestion of nonnutritive items..." 1. Review of Client 1's medical record on 6/14/12, revealed that Client 1 was admitted to the facility on 5/4/87 and had diagnoses that included pica and severe intellectual disabilities. The record revealed that Client 1 had a long-standing history of pica and the facility had a plan of care regarding Client 1's pica behaviors. Review of a Behavior Support Plan for pica, dated 4/18/12, indicated Client 1 was on close supervision on his residence (visual checks every 5 minutes). He was to be visible in public areas unless he was in the bathroom or in his room. For any off-residence activity (offsite / outing) he was on constant supervision (Staff was required to be able to see and or hear each client and be in close enough proximity to intervene as necessary). On 5/17/12, facility documentation indicated that Client 1 vomited coffee ground emesis (an indicator of bleeding in the stomach) and was sent to the community hospital. On 5/18/12, the client underwent a procedure to extract a button, button pieces, a shoelace and two calcified gloves. Upon return to the facility, the client was placed on Individual Supervision at all times. Review of a subsequent Behavior Support Plan for pica, dated 6/1/12, indicated Client 1 was on Individual Supervision, (Staff must be able to see their assigned client at all times and be in close enough proximity to protect them and others from injury. Staff must not leave the client unattended at any time or be distracted by other issues). A facility document, dated 6/13/12, indicated that on 6/9/12, staff noted that the client, while on individual supervision, had collected pieces of wood from his bed frame under his covers. An interdisciplinary note indicated that no ingestion was witnessed. 2. A review of Client 2's medical record on 6/14/12, indicated that Client 2 was re-admitted to the facility on 8/26/11, with diagnoses that included pica, Intermittent Explosive Disorder, and severe mental retardation. Review of facility documentation dated 6/13/12, indicated that Client 2 presented with symptoms of a possible bowel obstruction and was transferred to the acute care hospital for evaluation and treatment. The documentation also revealed that the Computerized Tomography scan showed the presence of a "V" shaped wire type foreign body with small rounded metallic ends traversing his small bowel. The Computerized Tomography scan indicated that Client 2's small bowel appeared to be perforated.Emergency surgery was performed and the "V" shaped item was removed as well as two arm pieces from a pair of eye glasses. The facility document indicated that Client 2 had a history of ingestion of non-food items, specifically sunglasses. The documentation further indicated that this was the second incident involving the ingestion of sunglasses with Client 2 within the past 12 months. In March of 2009, Client 2 had an esophageal perforation due to ingestion of a linear object. A review of Client 2's Behavior Support Plans, dated 5/11/12, indicated that Client 2's Target Behaviors included property destruction (breaks medical equipment, electronics, windows, sunglasses, ...) and pica ( putting hazardous objects in his mouth or ingesting such objects (may include toys, blankets, paper clips, light bulbs, sunglasses,... , and other objects that he breaks). Client 2's behavior plans listed sunglasses as "Preferred Items." Psychology Progress Notes, dated 1/11/12, indicated that in the 4 months since the client's return to the facility on 8/26/11, there were 17 incidents of pica or attempts.On 6/20/12, review of a facility document relating to an "Endangering Event- Ingestion," indicated the following Issue/Concern: "Poor planning by the ID Team (Interdisciplinary Team) regarding client needs and supports." Client 2's level of supervision was changed from individual supervision to general supervision on 3/11/12, following his dismantling a pair of sunglasses and ingesting a piece of the lens on 10/29/11. "No denial of rights was put in place to monitor his possessions for ingestible type items and following the 10/29/11 incident, the client was still allowed to have sunglasses despite his long history of attempting to and actually ingesting them." Observations on 6/12/12 at 4:45 p.m., revealed a housekeeping cart parked in the doorway of an activity room on Client 2's residence, accessible to clients ambulating in the hallway who potentially had pica. The housekeeping employee had his back to the cart as he cleaned in the room. The garbage container was not covered and an open container of disposable gloves was on the top of the cart. Staff A stated there were clients with pica behaviors on the unit. On 9/18/12, review of the operative report, dated 6/13/12, indicated that the post-operative diagnosis was a perforated small bowel secondary to ingested foreign body. The procedures performed were as follows: 1. Exploratory lap (an incision through the abdominal wall). 2. Excision of foreign body from the small bowel. 3. Small bowel resection (excision) with side to side functional end to end stapled anastomosis (surgical connection between two structures). 4. Abdominal washout. On 9/18/12, a physician's general surgery note indicated: Routine follow up 3 weeks status post emergency exploratory laparotomy for small bowel perforation secondary to swallowed glasses which was complicated by post op abscess requiring [unable to read] drainage. Therefore, by failing to protect clients from health and safety hazards and by failing to implement pica related policies and procedures, Client 1 ingested gloves and other items requiring surgery to remove the items from his stomach and subsequently obtained pieces of a wooden bed frame while on individual supervision. Client 2 required emergency surgery after ingesting sunglasses, despite a long history of attempting to and actually ingesting them. 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. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009498 |
AA |
12-Dec-12 |
HJ6711 |
20780 |
T22 DIV5 CH8 ART3 - 76301e Required Services (e) Client care provided by all team members shall be safe and considerate as ordered or indicated by the needs of the client and in accordance with acceptable standards of practice. The facility violated the above regulations when Client 1 suffered in pain and then died from peritonitis when physicians and nurses failed to identify and treat an incorrectly positioned gastrostomy tube, when nursing policies pertaining to care and use of gastrostomy tubes did not reflect safest practices and manufacturer's instructions, and when nursing staff failed to implement policies related to replacement of gastrostomy tubes after traumatic removal as follows: On 6/20/12 at 11:30 a.m., Client 1's clinical record was reviewed. The record reflected the following: A review of Interdisciplinary Notes (IDNs) dated 5/9/12 at 11:10 p.m., documented Client 1 was found in his room by night shift staff during change of shift rounds. Client 1 was pale, cool to the touch and unresponsive with no pulse and respirations. Physician Progress Notes (PPNs) of 5/9/12, indicated Client 1 was found in a recliner at 10:35 p.m. Cardiopulmonary resuscitation was not successful and Client 1 was pronounced dead at 11:10 p.m. At the time of the investigation the autopsy report was not available. During interview on 6/25/12 at 11:30 a.m., a representative of the coroner's office stated the cause of death was, "Acute Peritonitis". (An inflammation of the membrane which lines the inside of the abdomen and all of the internal organs. This membrane is called the peritoneum.) An Individual Program Plan (IPP) dated 5/5/11, documented Client 1's diagnoses included profound mental retardation, obsessive-compulsive disorder, hearing loss and visual impairment. Client 1 was non-verbal and communicated with body language, facial expressions, and gestures. He had compulsive behaviors of spinning and twirling while walking and would sit on the floor instead of a chair. He also would lick poles, trees, and doors. The IPP documented Client 1 had a gastrostomy tube placed 4/13/11, due to swallowing problems, and recurrent aspiration pneumonia. A special meeting note dated 12/8/11, indicated Client 1 pulled his gastrostomy tube out on 12/4/11. An X-ray report dated 12/5/11, indicated contrast injected through the tube was seen in the stomach and duodenum with no extravasation (leaking) of contrast fluid. A review of IDNs of 3/5/12, documented Client 1 was seen in surgical clinic where a skin level gastrostomy tube was inserted. A review of PPNs dated 3/7/12, documented Client 1's primary physician (Physician A) administered acupuncture treatments in physical medicine clinic for a diagnosis of Gastroesophageal Reflux Disease (GERD) and pain. [GERD is a condition in which the stomach contents (food or liquid) leak backwards from the stomach into the esophagus, the tube from the mouth to the stomach. This can irritate the esophagus causing heartburn and other symptoms.] A review of IDNs of 3/26/12, indicated a coffee ground residual was noted of 125 cc. PPNs indicated the primary physician documented an emesis with the appearance of coffee grounds in the amount of 120 cc. The notes did not document an examination of the gastrostomy tube. The physician's impression was a probable recurrence of a bacterial (H. Pylori) gastritis. A review of IDNs of 3/30/12, indicated Client 1 was having a morning formula nourishment via bolus when he screamed for about 10 seconds and then had a seizure. Notes indicated Client 1 had been seizure free since 1977. Notes of 3/31/12, indicated Client 1 seemed restless and tolerated his gastrostomy feeding but was tucking his arms under his seatbelt (a form of self-restraint). A review of PPNs of 3/30/12, documented a visit by Physician A and the impression that the seizure could be an isolated incident or a reaction to the antibiotic treatment for gastritis. A review of IDNs of 4/4/12, indicated Client 1 had 2 cc of clear residual at 3 a.m. At 8:45 a.m., Client 1 was noted to be short of breath with a pulse of 104 and a respiratory rate of 14. At 9 a.m., a Medical Emergency was called when staff noted Client 1 was tired and pale and had a decreased respiratory rate. Notes of 4/5/12 at 2:45 a.m., documented Client 1 had an elevated heart rate of 129 beats per minute and increased respiratory rate of 26. A review of PPNs dated 4/4/12 at 9:10 a.m., documented the primary physician examined Client 1 and noted the gastrostomy tube was patent and clean. PPNs of 4/5/12 at 10:15 a.m., indicated the physician's impression of possible aspiration pneumonia. Notes indicated the gastrostomy was clean and the abdomen was not distended. A review of notes by a Health Services Specialist (RN) of 4/5/12 at 11:50 a.m., indicated a pulse of 129 and respirations of 30. Notes at 7:45 p.m., indicated staff noticed dried blood around the gastrostomy stoma site and blood in the residual. A review of IDNs of 4/6/12 at 4 a.m., indicated a small amount of bleeding and dried amount of blood at the stoma site. IDNs of 4/6/12 at 12:30 a.m., documented a visit by a Health Services Specialist (RN) who noted a small amount of dried blood at the stoma site with an area of pink tissue surrounding the stoma. Staff reported the tube seemed tight. There was an odor to the stoma site. The physician was notified. A review of PPNs did not indicate a visit by the physician. A review of IDNs of 4/6/12 at 2:30 p.m., indicated staff again noted dried blood around the stoma and Client 1 was exhibiting distress with behaviors of licking his fingers during feedings.Notes of 4/7/12 at 4 a.m. showed Client 1 was agitated during the feeding and licking at his fingers. Acetaminophen (Tylenol) elixir was given via the tube for discomfort. Notes indicated there continued to be dried blood around the stoma. Notes of 4/9/12, indicated the stoma had an area with a greenish color and slight redness around the stoma. A review of IDNs of 4/11/12, indicated Client 1 was receiving acetaminophen elixir via the gastrostomy for pain. Notes indicated he was exhibiting loud vocalizations and restlessness.Notes of 4/12/12, indicated Client 1 was very agitated during the 9 a.m. feeding. Staff administered acetaminophen with hydrocodone (Norco is used to relieve moderate to severe pain). Notes of 4/13/12, indicated the stoma area was red with dried blood around it. Notes of 4/15/12, indicated there was no residual noted at 8 a.m. and 5 cc noted at 12 noon. The stoma area was continued to be red and bleeding continued.There was no indication of a visit by the physician. A review of IDNs of 4/16/12 at 4:30 a.m., indicated Client 1 had two days of loud vocalizations and no sleep. He was given medication for pain with no reduction in vocalizations. At the time of feeding there was coffee ground residual of 10 cc. Staff continued to give medications and formula through the gastrostomy tube. Notes at 2 p.m., indicated Client 1 continued to be restless and exhibiting loud vocalizations. Notes of 4/17/12, documented Client 1 continued to be restless with vocalizations. There was no indication of a visit by the physician. A review of IDNs of 4/18/12, indicated Client 1 was receiving Norco for pain. Crusty matter was noted around the stoma. During the 9 a.m. feeding Client 1 was very vocal with pain noticed in his facial expression. Notes of 6:30 p.m., indicated Client 1 was having discomfort exhibited by vocalizations and moving arms and hands up and down. Norco was given at 7 p.m. because Client 1 continued to exhibit cry-like vocalizations. When gastric residuals had the appearance of coffee grounds, staff administered Maalox via the gastrostomy tube. A review of PPNs of 4/19/12, documented a visit by the primary physician, Physician A. The previous visit was on 4/5/12. The notes indicated the physician was notified of the residuals with the appearance of coffee grounds seen the previous evening. Notes documented the physician's impression of gastritis, causing nocturnal agitation and insomnia. A medication for sleep was prescribed. In addition, notes indicated Client 1 was receiving an antidepressant and a medication to reduce the production of stomach acid. Medications were being given via gastrostomy tube. A review of IDNs of 4/21/12, documented Client 1 was itching himself all over and making disturbing loud vocalizations. He occasionally would start to cry. Posey mitts were ordered to protect his skin from self-injury. He continued to vocalize loudly. On 4/23/12, Client 1 continued to require mitts due to self-abusive behaviors of hitting himself. He was receiving Norco for pain as well as Maalox via the tube in addition to his regular medications and feedings. He was crying. On 4/24/12, Client 1 was writhing and restless. Notes of 4/24/12 at 4:30 p.m., documented that Client 1 was vocalizing loudly during the feeding and sweating profusely throughout the afternoon. A review of PPNs dated 4/24/12, indicated Client 1 had increased agitation, was sweaty, and vocalizing. The physician's impression was probable gastritis and possible constipation. A review of special meeting notes dated 4/25/12, indicated Client 1 recently had become combative during the feedings. A review of IDNs of 4/25/12, indicated Client 1 continued to perspire excessively during the day and was fidgety. At 9 p.m. Client 1 was yelling and rubbing his face so Posey mitts were applied and Norco was given. On 4/26/12, Client 1 was awake all night and restless. Staff administered two tablets of Norco every six hours for pain. On 4/27/12, Client 1 was awake all night and continued to be restless and fidgeting during gastrostomy feedings. Two staff were required to complete the feedings. At 9:15 a.m. he was restless and sweaty during the gastrostomy feeding. Staff administered the sedative medication Lorazepam. A review of PPNs dated 4/27/12, documented Client 1 was having severe agitation with self-injurious behaviors. The physician prescribed the sedative Lorazepam to be administered through the gastrostomy tube. The note documented the primary physician spoke with Client 1's relative who, according to the physician, did not understand his simple explanation of why (Client 1) was agitated and symptomatic.The note documented the physician told the relative that Client 1 had a behavior of licking his shoes and the floor and reinfected himself with the H. pylori organism there-by needing repeated treatment every so often.The physician told the relative that Client 1's body may not tolerate the recurrent gastritis. A review of IDNs of 4/28/12, indicated that Client 1 was writhing constantly and resistive to care. On 4/29/12 Client 1 was unsteady with erratic movements and anxious. There was marked sweating over his body. He was exhibiting painful facial grimacing during the 12 noon feeding and was given two tablets of Norco. A review of IDNs of 5/2/12 at 2 a.m., showed Client 1 was very agitated and was rubbing his skin constantly causing the skin of the abdomen and thighs to be bright red. Acetaminophen was given but was not effective so the physician on call ordered a sedative. A review of PPNs of 5/2/12, documented Client 1 received acupuncture treatment from his primary physician for his GERD. A review of IDNs of 5/2/12 at 11 a.m., documented that during the morning feeding, both of Client 1's legs were shaking and he was self-restraining both hands and arms behind him in the back of the wheelchair. A review of special meeting notes dated 5/3/12, indicated the team met to discuss Client 1's increase in agitation over the past months. The team identified that Client 1's behavior began escalating around 4/25/12. Although he had always exhibited these behaviors, they had never been so severe. Client 1 was not sleeping at night. It was very difficult to feed him due to his resistiveness. He continued to receive his medications by gastrostomy tube. He frequently dropped to the floor and then licked the floor. He often pressed his fists into his eyes. It was not uncommon for him to moan. He often writhed and perspired. The meeting notes documented the unit physician stated Client 1 was experiencing significant discomfort and pain due to a severe case of gastritis and Client 1 had recurrent gastritis as a result of his repeated licking of the floor. A review of IDNs of 5/2/12 at 8 p.m., indicated Client 1 was resistive to receiving medications and gastrostomy feedings. Notes of 5/3/12 at 1:30 p.m., indicated the skin of his thighs and thorax was scratched from Client 1 putting his hands down his pants for self-restraint. Notes written at 2:15 p.m., indicated he tipped his wheel chair over and was pushing staff away from him, vocalizing loudly, flailing his arms and legs, and trying to hit his head on the floor. Two staff were necessary to intervene. He continued out of control behavior trying to hit his head. The physician ordered a sedative to be given through the gastrostomy. Notes indicated the physician changed many orders. The last PPN by the primary physician, Physician A, dated 5/4/12 at 10:30 a.m., indicated, "Client had a good night last night. Slept very well ... (illegible) ... I believe client scratching himself greatly today, required Posey mitts. The notes did not indicate a physical examination of Client 1. A review of IDNs of 5/4/12 at 5:15 p.m., indicated Client 1 was given a sedative because he was trying to hit his head on the floor and was scratching his body, hitting and kicking at staff. He refused to stop these behaviors and Posey mitts were applied. IDNs of 5/5/12 at 3 p.m., indicated the morning feeding was very difficult due to Client 1's uncontrollable behaviors due to his pain. He required physical restraint in the wheelchair and received sedation. Notes of 5/6/12 and 5/7/12, indicated Client 1 continued the same behaviors. Notes of 5/7/12, indicated he grabbed at staff hand during his 12 noon feeding. At 9 p.m. he hit his head and sustained a laceration on the top of the scalp. A review of PPNs from 3/7/12, 3/26/12, 3/30/12, 4/4/12, 4/5/12, 4/19/12, 4/24/12, 4/25/12, 4/28/12, 5/2/12, 5/3/12, and 5/4/12 did not document any evidence Physician A considered ordering any test to ensure proper placement of the gastrostomy tube. A review of Client 1's Physician's Orders indicated, "Since 3/5/12, on feeding tube with a low profile mini one button GT. Size 20 FR w/3.5 cm w/10 ml balloon." A review of the "INSTRUCTIONS FOR USE" for the AMT MINI ONE skin level indicated, "VERIFY THE MINI ONE IS WITHIN THE STOMACH ... "Attach a catheter tip syringe with 5 ml of water into the Mini ONE button feeding set. Aspirate for contents. Spontaneous return of gastric contents should occur. WARNING: NEVER INJECT AIR INTO THE MINI ONE BUTTON." On 6/21/12 at 2 p.m., a review of the facility document entitled, "GASTROSTOMY TUBE" dated February 2011, under the heading of, "Residual and Placement Checks" indicated, "Attach a feeding syringe to end of tube, lower the syringe below stomach level to allow gravity to fill syringe ..." and "... If there is no return do one of the following: ... Auscultation: Inject 10-20 ml (milliliter) of air in the GT (gastrostomy tube) while listening for a loud whooshing or gurgling sound in upper left quadrant of abdomen using a stethoscope." Auscultation is the act of listening to sounds arising within organs (as the lungs or heart) as an aid to diagnosis and treatment. Aspiration is breathing in a foreign object or liquid. Reference review on 6/21/12, indicated: ("... Do not use an auscultation method to check tube placement: it is not reliable." Preventing Aspiration During ... Gastrostomy Tube Feedings. Janice L. Palmer, MS, RN: Norma A. Metheny PhD, RN, FAAN. American Journal of Nursing, February 2008. Volume 108.") A review of Client 1's clinical record reflected the facility document, "ENTERAL FEEDING LOG". In the log, the area for tube placement verification indicated, "Verify placement each shift by residual checks ... If no residual = Use stethoscope to check w/10 cc (with 10 cc) air injected to check via auscultation." A review of the logs from January 2012 to May 2012 indicated gastric residuals were frequently recorded to be zero and there were initials in areas indicating confirmation of placement by injection of air. On 6/21/12 at 2 p.m., a review of the facility document entitled, "GASTROSTOMY TUBE" dated February 2011 indicated in bold underlined print, "... If the tube comes out and the balloon is intact (inflated), and with signs of trauma (e.g.bleeding) and with missing parts, notify the physician immediately." On 6/20/12, a review of Client 1's IDNs by a Psychiatric Technician (PT), (Staff C) on 5/8/12 at 7:15 p.m., indicated, "(Client 1) flailing his arms around. Client rec'd (received) stat programmed lorazepam (a sedative) 1 mg (milligram) GT for pain. He pushed staff away while staff was attempting to give medication and formula causing the GT to come out of his stomach. GT replaced (with) Foley GT. Some oozing of blood that was minimal." The notes did not indicate a physician was called immediately after the tube came out traumatically with bleeding. On 6/21/12 at 2 p.m. a review of the facility document entitled, "GASTROSTOMY TUBE" dated February 2011 indicated, "Balloon Gastrostomy Tube Placement.Performed by: Licensed level of care staff. (This means a Registered Nurse, a Licensed Vocational Nurse, or a Psychiatric Technician). On 6/21/12 at 6:15 p.m., a review of a revised procedure entitled, "GASTROSTOMY TUBE" dated June 2012 indicated, "Purpose: Direct licensed staff to appropriately place a gastrostomy tube ..." Neither the former or current policy described the limits of the conditions under which a Psychiatric Technician (PT) may insert a replacement gastrostomy tube. During a phone interview on 7/3/12, a representative of the California Board of Vocational Nursing and Psychiatric Technicians stated a PT may reinsert a gastrostomy tube in accordance with a physician's order into a well-healed, non-problematic tract. In all cases, the PT must possess the knowledge, skill and abilities to perform safely and competently. A review Client 1's clinical record reflected notes by a HSS dated 5/9/12, with no time indicated documented the Registered Nurse (RN) (Staff D) removed the Foley catheter. There was a small amount of dark red blood expelled with bile. The RN inserted a size 20 French 3.5 cm button (skin level tube). Notes indicated, "... button inserted [with] some resistance (tight abd muscles) then easily inserted again [with] bleeding noted@ ... stoma site. placement [check] via ausc (auscultation); scant blood in residual check. abd soft. balloon instilled [with] 10 cc water - tolerated well. Covering MD notified. Plan monitor site." A review of subsequent IDNs of 5/9/12, indicated Client 1 seemed to be comfortable and not in apparent pain. Notes indicated he was found in his room without pulse or respirations at 11:10 p.m. During an interview on 7/2/12 at 3 p.m., the facility physician who attended the autopsy (Physician B) stated Client 1 had a tense abdomen and as the abdomen was incised about 1500 cc of undigested formula came out. A skin level gastrostomy tube was positioned in the peritoneal cavity and not in the stomach. The physician stated Client 1 had peritonitis with the entire anterior wall of the abdomen inflamed with pus pockets around the internal organs. The physician described a congealed area by the liver and spleen. There were multiple pockets of pus. The physician stated there was an area of scars and pus next to the stomach. The physician described a formation between the abdominal wall and the stomach that looked like omentum (a fold of peritoneum extending from the stomach to adjacent abdominal organs.) The physician stated the peritonitis must have been going on for longer than a few days, possibly from a leak in the area of the stoma with part of the formula going into the stomach and part going into the peritoneal cavity. Physician B indicated this was most likely the reason for Client 1's pain and anxiety. Therefore the facility failed to provide the physician services necessary to diagnose and treat Client 1's misplaced gastrostomy tube. Nursing policies did not provide for nursing services to ensure correct gastrostomy tube placement and nurses did not follow the policies in effect for tube replacement after traumatic removal. Client 1 suffered in pain for months and then died of acute peritonitis when staff continued to use his misplaced gastrostomy tube. The facility failures presented an imminent danger to the patient and was a direct proximate cause of the death of the patient. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009501 |
A |
12-Dec-12 |
HJ6711 |
4107 |
T22 DIV 5 ART4 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. The facility violated the above regulation when it failed to ensure clients were not subjected to physical, sexual, and psychological abuse. The facility failed to ensure Clients 1 and 2 were free of physical, sexual, and psychological abuse when a male staff member exposed his genitals, grabbed the female clients' hands, forced and attempted to force the clients to touch his penis, and masturbated in their presence. 1. Review of Client 1's medical record on 6/1/12, revealed that Client 1 was admitted to the facility in 1989 with diagnoses including Severe Intellectual Disability and Bipolar Disorder. Client 1 had good receptive language skills and could follow simple directions. Her expressive communication consisted mainly of gestures and guiding people to what she wanted. She also used simple verbalizations. Client 1 required staff supervision for completion of activities of daily living.On 5/29/12, review of a facility document, dated 5/25/12, revealed Staff A was observed facing Client 1 about two feet away from Client 1. Staff A was sitting on the sink counter in the bathroom and had his shorts down and his penis out.The report indicated Staff A was immediately removed from client contact and a short while later arrested on felony charges by the county Sheriff Department.2. Review of Client 2's medical record on 6/1/12, revealed that Client 2 was admitted to the facility in 1991 with diagnoses including intellectual disability and aggressive behaviors. Client 2 had good receptive language skills. She expressed herself with gestures and could verbally mimic phrases of others. She indicated choices with hand gestures or by leading staff. She required general supervision in familiar environments.On 5/29/12, a review of a second facility document dated 5/26/12, revealed that a county Sheriff's deputy stated that Client 1's roommate, Client 2 was also a victim of sexual abuse by Staff A.On 6/1/12, a review of Client 2's Physician Progress Notes (PPNs) dated 5/26/12, indicated Staff A, "... admitted to masturbating in the presence of ... (Client 2). He reported wanting (Client 2) to touch him. It is unclear to me whether employee asked (Client 2) to touch him + (and) she refused, or whether he placed her hand on his genital area + (and) she pulled away. This episode occurred sometime within the past 1 - 2 weeks."3. Review of a "CRIMEINCIDENT REPORT," dated 9/5/12, documented Staff A told a Sheriff's Department detective that he [Staff A] did,"something perverted." Staff A told the detective that he had Client 1 "fondle me." Staff A explained that he brought Client 1 into the bathroom where he was alone with her and then exposed his penis to her and took the victim's hand to place it on his penis. Staff A admitted to the detective that about one to two weeks ago, he attempted to have the victim's roommate, Client 2, fondle his penis by having his pants partially down, penis exposed, and he grabbed Client 2's hand ... however she pulled back refusing to touch his penis. The report indicated the detective interviewed a psychiatric technician assistant who stated approximately two months earlier (approximately April 9, 2012) Client 2 appeared so happy and said, '(Staff A) is not here." The PTA indicated Staff A was not at work that day. Therefore the facility failed to ensure clients were not subjected to physical, sexual, or psychological abuse. Staff A confessed to physically and sexually abusing Clients 1 and Client 2.The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009503 |
A |
12-Dec-12 |
HJ6711 |
4861 |
Title 22 DIV 5 ART4 76525 (a) (20) CLIENTS' RIGHTS76525 (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to comply with the above regulations by failing to ensure that facility staff used appropriate interventions to manage inappropriate client behavior with sufficient safeguards and supervision to ensure that the safety, welfare and civil and human rights of clients were adequately protected. On 6/13/12, a staff member used excessive force and a potentially injurious physical hold to redirect Client 1. A review of Client 1's medical record on 6/13/12 revealed that Client 1 had diagnoses including severe mental disability, Intermittent Explosive Disorder, and a seizure disorder. Client 1 was non-verbal and made his needs known by pointing, gestures, and facial expressions. Observations on 6/13/12 at 4:25 p.m., revealed Client 1 at the unit entrance with a distressed expression on his face. The Unit Supervisor, (Staff A) stated, "He might hit you," and the supervisor entered the unit while the surveyor waited in the foyer of the unit. A few seconds later Staff A returned to escort the surveyor into the unit. Staff B was observed propelling Client 1 down the hall, with Client 1 bent forward with arms rotated inward and rigidly hyperextended behind Client 1. Staff B was holding Client 1 at the wrists and steering Client 1 down the hall toward the door to the outside patio. During a concurrent interview when asked if physical containment was part of Client 1's behavior plan, Staff A stated Client 1 had attacked her in the hall and had grabbed her clothing and her hair. The US stated she had restrained Client 1 by the wrists to gain release of her hair and to protect herself.Staff A stated she had been on the unit only a few months and did not have the behavior plans memorized. Review of Client 1's behavior support plan for assault dated 9/2/09, indicated behavioral antecedents included whining, distressed facial expression, raising a fist above his head, and charging at staff or another client. Interventions included asking him to stop, asking what he might need, and offering him choices regarding what he wanted. If he was still escalating staff were to verbally prompt him to sit down away from other clients.The plans indicated Client 1 would typically cry as he calmed down. After the incident he enjoyed physical reassurance such as shoulder pats and hugs which could help in preventing another episode. The behavior plan did not include physical prompts, or physical compliance such as the containment method used by Staff B. At 4:30 p.m., Staff B and Client 1 were at the nurses' station counter. Client 1 was sobbing with tears and runny nose. During concurrent interview, when asked if he learned that hold in Management of Assaultive Behavior, Staff B said, "No. Well maybe a version of it. There was no one to help me out." When asked if such a hold could injure a client's joints, Staff B demonstrated a "safer hold" by putting his hands on Client 1's upper arms. During an interview at 5 p.m., with Staff A and the unit psychologist (Staff C), Staff C stated a safe physical containment required at least two people and might take four people to provide a safe physical containment. Staff A stated Staff B had no way to summon help for an emergency physical containment.Staff A stated the unit was large and there was no way to hear a staff's cries for other staff to assist. If other staff did come to help, the clients for whom they were providing supervision would be left alone. Review of the facility document, on 6/13/12, entitled, "Self Defense and Management of Assaultive Behavior," dated July 2010, indicated, "There are no one-person escort techniques. AT LEAST two staff members are required to safely transport an individual from one place to another." The document indicated that one person physical containment was prohibited as of January 1, 2010. Therefore, the facility failed to comply with the above regulations by failing to ensure that staff used interventions to manage inappropriate client behavior with sufficient safeguards and supervision to ensure that the safety, welfare and civil and human rights of clients were adequately protected. A staff member used excessive force and a potentially injurious physical hold to redirect Client 1. 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. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009606 |
A |
12-Dec-12 |
T8MH11 |
5269 |
T22 DIV5 CH8 ART4-76525(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. The facility failed to comply with the above regulations by failing to ensure that Client 1 with a severe life threatening behavior, pica (the persistent ingestion of nonnutritive substances including, but not limited to: clay, dirt, sand, stones, hair, feces, lead, gloves, plastic, paper, paint chips, wood, string, cloth, metal, and/or cigarette butts) who was on 1:1 (one to one) constant observation, was not neglected by failing to supervise Client 1 in accordance with his individual program plan; and the facility failed to have his safety adequately protected when his designated 1:1 staff fell asleep while on duty, as follows:Review of Client 1's record on 11/13/12 at approximately 1:45 p.m., showed Client 1 had diagnoses of pica, autism, and severe intellectual disabilities. Review further revealed that Client 1 had a history of ingested inedible objects such as "coins, gloves, plastic ware, candy wrappers, paper, etc." A report received from the facility on 11/13/12, revealed that on the morning of 11/11/12, program management made rounds at 3:55 a.m. The program manager stopped by Client 1's room. The door was open and the staff person assigned to provide individual supervision, Staff B, appeared to be sleeping, sitting in a chair with head bent to the side and eyes closed. Per the report, the manager had to knock on the door twice before the staff person awakened. Further review of Client 1's record revealed an annual psychological evaluation update with functional analysis dated 11/2/12, which described four incidents of severe life threatening pica: 1. July 1987 - bowel obstruction caused by 1 inch x 8 inch rag, metal foreign body also noted; 2. October 1990 - bowel obstruction caused by bezoar ("a hard mass of entangled material ...", Tabers Edition 15) consisting of string, plastic wrapper, and paper, there was also a wad of material in the rectal sling; 3. an incident in January 2009 where plastic cutlery, candy wrappers and gloves were found in the client's bowel, foreign matter was found in the stomach, there was a tear of the esophagus near the stomach, a fistula was noted between the esophagus and lung, and there was infection in greater than half of one lung. Further review showed that on 5/17/12, Client 1 was sent to an acute care hospital due to a large bloody emesis. Review of records from the acute care hospital showed that on 5/18/12, Client 1 underwent an upper endoscopy (the placement of a tube into a patient's stomach) which revealed plastic gloves in the stomach. The procedure was unsuccessful in removing all of the gloves, only one glove was removed, so it was decided that a Laparoscopic gastrostomy was required.An operative report from the acute care hospital dated May 18, 2012 showed that during the laparoscopic procedure 2 more gloves were removed as well as a shoelace. Client 1 returned to the facility on 5/27/2012 from the acute care hospital. On 5/30/12, a special meeting was held to review the client's Individual Program Plan (IPP). Review of the IPP revealed, "This full team special meeting was held regarding the recent pica episode that resulted in hospitalization and surgery. A shoelace and three gloves were removed from his stomach. He was admitted to [acute care hospital] on 5/17/2012 and returned to Smith on 5/27/12. Upon return he was assigned individual supervision for his safety to prevent further pica episodes." Review of Individual Supervision (1:1) Guidelines for Client 1 dated 5/31/12, under main points revealed, "1. Staff must provide direct, full line-of-sight supervision within arm's reach at all times to prevent life-threatening pica. And "2. Staff must first obtain a substitute staff to be designated as 1:1 before taking a break."Review of the Individual Plan Behavior Objectives and Plan showed that the plan was updated on 6/4/12 for Individual Supervision. Under Prevention the plan showed: "1. Supervision: [Client 1] is on Individual Supervision = provide direct, full line-of-sight, within arm's reach at all times to ensure his safety. ...know what his hands are doing at all times..." During interview of a supervisory staff (Staff A), on 11/13/12 at 2:30 p.m., Staff A stated that Client 1 had been on 1:1 status since May 2012 and was to be on 1:1 supervision at all times for pica. The facility failed to ensure that Client 1, who has severe life threatening behavior, pica, who is on 1:1 constant supervision, was not neglected, failed to supervise the client in accordance with his individual program plan, and failed to have his safety adequately protected when his designated 1:1 staff fell asleep while on duty.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. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009607 |
A |
21-Feb-14 |
CEJL11 |
16881 |
T22 DIV5 CH8 ART4-76525 (a) (20)(a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights:(20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to ensure clients' right to be free from harm when it failed to implement systems designed to identify risk and prevent harm. Over a period of six months, Client 1 inflicted bites with increasing seriousness of tissue damage to Clients 2, 3, and 4 as follows:Review of a social history evaluation, dated 12/5/11, documented Client 1 had diagnoses including Post-Traumatic Stress Disorder (PTSD) (a mental health condition that is triggered by a terrifying event with symptoms including flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event) and Moderate Intellectual Disability. The evaluation indicated Client 1 had a history of biting individuals who intruded into her personal space and was on general supervision, meaning that staff monitored her whereabouts at least every 15 minutes. The document indicated Client 1 was sensitive to loud noises, such as yelling, and had a history of reacting by biting.A review of an incident report, dated 4/4/12, documented Client 1 attacked Client 2 during dinner. Client 2 sustained a bite wound of the left forearm. The skin was not broken but there were visible teeth impressions with swelling and bruising. The report indicated the team identified the absence of familiar staff as a possible antecedent to Client 1's outburst. The report documented Client 1 had had four previous incidents of biting peers over the past twelve months and remained on general supervision. An incident report of 6/16/12, documented Client 2 surprised Client 1 while Client 1 was alone watching TV. Client 1 jumped up, grabbed Client 2 by the neck, and started to bite Client 2 on the arm. It took several attempts for staff to successfully separate the two clients. Client 2 sustained four obvious bite marks with full mouth impressions and bruising. Three bites had broken the skin. In addition Client 2 sustained scratches under the left eye and left neck. The report identified that the staff member with Client 2 did not know Client 1 was relaxing in the TV room. Staff opened the door and Client 2 startled Client 1. The report indicated that the Unit Supervisor determined Client 1 was safe and resumed her status of general supervision.On 11/29/12, a review of an incident report, dated 10/23/12 at 4:30 p.m., documented that Client 1 inflicted five bite wounds to Client 3 while Client 3 was sitting on the toilet in their shared bathroom. The report indicated the bites were severe in that they caused broken skin and tissue damage. Client 3 sustained bite wounds to her third finger, left upper outer thigh, left inner thigh, left lower anterior thorax, and right inner thigh.Client 1 was on general supervision at the time and was placed on close supervision after the incident until she calmed about an hour later.Observations of copies of photographs of Client 3's wounds revealed five skin openings with a large area of bruising surrounding a bite wound on the right thigh. A review of Interdisciplinary Notes (IDNs), dated 10/23/12, documented swelling of all the wounds with the right thigh wound measuring 5 centimeter (cm) with a 10 cm purple bruise surrounding the opening along with a large amount of swelling.A review of Client 3's Individual Program Plan, dated 12/13/11, documented Client 3 had diagnoses including PTSD and Mild Intellectual Disability. A review of a psychology progress note, dated 10/24/12, indicated, "Yesterday evening, client was bitten seven times by a peer ... This morning...She stated that she was very upset ...was 'very scared,' 'in a lot of pain,' and, 'I don't want to live here anymore.' ... She stated that she 'Couldn't stop crying last night.' ..." During an interview on 11/30/12 at 12:15 p.m., 42 days after the incident, Client 3 exhibited her five healing bite wounds. Observations revealed two wounds were still open but scabbed over. Client 3 stated the wounds had become infected and she had needed antibiotics.During the interview on 11/30/12, Client 3 stated she and Client 1 were friendly neighbors who recently were moved to bedrooms next to each other with a shared bathroom in between. Client 3 stated Client 1 had PTSD and just snapped, all of a sudden. Client 3 stated there were two new clients screaming in the hall outside their rooms when Client 1 became agitated on 10/23/12. Client 3 stated she was on the toilet when she saw Client 1's feet under her stall door. Client 3 stated she told Client 1 that she was using that toilet, but Client 1 did not respond as Client 1 usually did. Client 3 stated the latch on the stall door was broken and Client 1 entered the stall and attacked her. Client 2 stated she became tangled in her lowered trouser legs and both she and Client 1 fell to the floor. Client 3 stated she was crying and screaming for help, but the new clients were still screaming in the hallway and staff did not immediately respond to her calls. Client 3 stated Client 1 had her teeth latched on one of her fingers and she feared Client 1 would bite her finger off. Client 3 stated she bent her finger to prevent a complete amputation. Client 3 stated during the struggle, the fingers of her other hand ended up in Client 1's eye socket, but she did not want to hurt Client 1, so she put a knee in Client 1's chest and moved her hand down to grab Client 1 around the throat. Client 3 stated she pressed on Client 1's Adam's apple area and Client 1 finally released her bite on the finger. After that, a staff member arrived to take Client 1 to her room. During the interview on 11/30/12, Client 3 stated that "a couple of days ago" Client 1 had come at her again. Client 3 stated she was awakened in her sleep by the sounds of an agitated Client 1 rattling the knob on the locked door between Client 3's bedroom and the shared bathroom. Client 3 stated, "I was screaming...I got up and left my room." "I told them (staff) I was scared." During the interview on 11/30/12, Client 3 stated, "I don't feel safe with her being right by me." Client 3 stated Client 1 did not have extra staff supervision at night. Client 3 stated there was a lock on the door between the shared bathroom and her bedroom. Client 3 stated staff expected her to unlock that door, enter the bathroom, lock the door to Client 1's room, use the toilet, then unlock the door to Client 1's room, exit the bathroom and lock the door to her bedroom. Client 3 said, "I'm scared. What if I accidentally forget a lock? I'm scared for my life...What am I supposed to do? Next time I might have to hurt her bad. I don't want that. I don't want to kill someone in self-defense." During the interview on 11/30/12, Client 3 said, "Maybe that's why I am having panic attacks at night." Client 3 stated she had nightmares, "...every night ..." that somebody was choking her. Client 3 stated she had a nightmare where somebody was biting her on the neck.On 11/30/12 at 2 p.m., observations in the bathroom shared by Clients 1 and 3 revealed the latch to the stall where the incident occurred was broken. During concurrent interview, Client 3 stated the latch was fixed after she was bitten, but Client 1 broke it again. Observations revealed a handmade sign on Client 3's interior door, "Don't forget to lock it !!" During concurrent interview, Client 3 stated she made the sign herself, but still staff members sometimes forgot to lock the door. Observations on 11/30/12 at 2 p.m. revealed Client 1 had a full set of intact straight teeth. Observations of her room revealed a bed position alarm (triggered if the client got up) known as an RN+ on her bed. During concurrent interview, a direct care staff (Staff C) stated Client 1 had individual 1:1 supervision during the day and evening shifts. At night, the bed alarm would sound at the nurses' station if Client 1 got out of her bed. Observations revealed a device attached to the exterior bedroom door. During concurrent interview, Staff C stated the device would trigger an audible alarm at the nurses' station if Client 1 left her room at night and entered the hallway. During concurrent interview, Staff D stated the device on the door kept falling down. When asked to demonstrate the bed and door devices, Staff C and Staff D could not make them work. During interview on 11/30/12 at 3:30 p.m., when inquiry was made regarding Client 3's safety at night, the Unit Physician (Staff B) stated, "I have no idea if it's safe. It's a behavioral issue."During interview at the same time, the Unit Supervisor (Staff E) stated Client 3 was safe because Client 1 has an RN+. Staff E stated Client 3 has to remember to lock her door. Staff E stated she was the one who was afraid and, "She knows how to lock her door."When inquiry was made as to the possibility that Client 3 might open the bathroom door to find Client 1 in the bathroom and possibly surprise Client 1 in the night, Staff E stated Client 3 should just back out, close the door, and lock it. When asked if surprising Client 1 in the bathroom might trigger another PTSD attack, Staff E stated, "There is always that potential." During the interview on 11/30/12, Client 3 stated that a few weeks after she was bitten, Client 1 bit Client 4 and locked her teeth on him. Client 3 stated Client 4 told her he was scared. A review of Client 4's clinical record reflected diagnoses including Moderate Intellectual Disability and Diabetes. An Annual Medical Summary dated 4/30/12 documented Client 4 was at risk for cellulitis (infections of the skin) due to his insulin dependent diabetes. During an interview on 11/30/12 at 11 a.m., the Unit Supervisor of a day program (Staff A) stated he was present when Client 1 inflicted bite wounds on Client 4 on 11/9/12 at 1:40 p.m. Staff A stated Client 4 was upset about not having ice cream so program staff escorted Client 4 back to the unit early. Upon entering the unit, Client 4 dropped to the floor and continued screaming for ice cream. Staff A stated he left Client 4 alone to calm down, because the area seemed quiet. Staff A stated Client 4's behavior plans clearly stated to ignore the outbursts and leave him in a quiet area. A review of Client 4's behavior support plans (BSP) dated 9/26/11 indicated, "If (Client 4) drops to the ground during the (physical) escort, clear area of peers and back away ... Once in a quiet area, ... follow (the) intervention steps ..." A review of the interventions listed in the document indicated, "Ask (Client 4) to 'stop' and separate him from peers ...Work to resolve the conflict ... Praise (Client 4) for relaxing ... When he is ready, encourage him back into his schedule ...". A review of Client 4's BSP of 9/26/11 did not indicate Client 4 should be left alone, unsupervised, during an outburst. During an interview on 11/29/12, the Unit Supervisor, Staff E, stated staff should not leave any client alone during a tantrum. Staff E stated, "It is not safe to leave. A client could engage in self-injurious behaviors when agitated."During the interview on 11/30/12 at 11 a.m., Staff A stated program staff were not aware Client 1 was at home in her room located on the hallway where Client 4 had dropped to the floor. Staff A stated he went around the corner to the nurses' station and seconds later heard Client 4 screaming for help. Staff A returned and saw Client 4 covered in blood with Client 1 on top of Client 4. Client 1 had her teeth latched on Client 4's shoulder. Blood was spurting from Client 4's front scalp. Out of the corner of his eye, Staff A saw a chunk of scalp tissue and hair on the floor.During an interview on 11/29/12 at 3 p.m., the Health Services Specialist (Registered Nurse Staff B) stated she was on the team that responded to unit staff calls of a medical emergency.Staff B stated there was blood squirting from Client 4's scalp above the forehead. The bleeding was so heavy Staff B could not visualize the wound. In addition Client 4 had a bite wound on the front of the left shoulder area. Staff B stated she made arrangements to have Client 4 taken to a nearby emergency room. Observations of copies of photographs of Client 4 and the scene of the incident revealed an open wound to the frontal scalp at Client 4's hairline, a large open bite wound with bruising of the left shoulder, and a third smaller skin opening at an unidentifiable site. In addition photographs documented evidence of blood loss with spatter patterns on the walls and ceiling. A review of interdisciplinary notes (IDNs), dated 11/10/12 at 9 p.m., documented the presence of two bite wounds to the left shoulder.A review of emergency room reports dated 11/9/12 documented a plastic surgeon reattached the piece of scalp over a denuded area measuring 7 cm by 5 cm on Client 4's head. The report documented, "Scalp degloving from human bite obviously at great risk for infection and the flap of tissue may or may not revascularize." A review of IDNs starting 11/15/12, documented Client 4's on-going treatment with oral antibiotics. Notes of 11/15/12, indicated an overwhelming foul odor from the scalp wound. Notes of 11/19/12, documented symptoms of tissue necrosis (death), with a foul odor. Notes of 11/21/12, indicated Client 4 developed a fever and there was an increase in necrosis of the wound and an increase in odor. Notes of 11/21/12 at 5:50 p.m. documented removal of the necrotic graft earlier in the day. Notes by a wound care nurse on 11/27/12, indicated slow healing of the wound which measured 6 cm by 4 cm with an area of necrotic tissue measuring 2.5 by 1.9 cm. A review of Client 4's Physician Progress Notes (PPNs) dated 11/21/12, documented necrosis of the graft. PPNs of 11/21/12 indicated the graft was removed on that date. PPNs of 11/30/12 indicated the area was now a granulating wound that was healing slowly. A review of an incident report dated 11/9/12 documented an initial review of the incident between Clients 1 and 4 and plans to place Client 1 on a "modified" constant supervision. Staff would enter her room when there was any disturbance to see if she was OK. Plans included staff posting themselves close to the area to be able to intervene as needed. The report indicated the BSP would be modified as needed and staff would be trained. On 11/30/12, a review of the clinical record reflected the most recent changes to Client 1's BSP were dated 11/7/12, two days before the incident with Client 4. Under the heading of, "Supervision level", interventions did not include those recommended in the above administrative reviews of the incident. The interventions did not include the individual supervision on the day and evening shifts, the RN+ bed alarm, and the door alarm at night, or the plans to lock the door to the bathroom shared with Client 3. On 11/30/12, a review of the, "Windows" for Client 1 did not reflect the planned interventions. The document, which was used by direct care staff continued to indicate, "... general supervision." A review of the facility document entitled, "CLIENT PROTECTION & PREVENTION FROM HARM", dated January 2012, indicated that a system of client protection was in place, which provided for, "thorough identification and assessment of potential risk, and immediate intervention when risk is present ..." The goal of the system was to, "...prevent incidents from occurring, track and analyze patterns and trends of incidents, develop and implement prompt and effective measures to minimize or eliminate occurrence in the future."Therefore, the facility failed to ensure implementation of policies designed to identify and intervene when risks were present resulting in the harm of neglect to Clients 1, 2, 3, and 4. Staff did not implement plans to redirect noisy clients away from Client 1 or check on Client 1 when other peers were having outbursts. Staff did not follow Client 4's plans when he was left alone during a tantrum. Client 1's written behavior plans were not updated to minimize the risks identified during administrative reviews including the risk of startling Client 1. When PTSD reactive episodes were triggered, Client 1 attacked Clients 2, 3 and 4, inflicting eleven open bite wounds as well as psychological harm. Clients 3 and 4 had deep wounds that became infected, required on-going medical treatment, and were slow to heal.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. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009611 |
B |
21-Feb-14 |
LJWW11 |
3378 |
Health and Safety Code - HSC DIV 2 CH 2.4 - Quality of Long-Term Health Facilities 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 facility failed to report an allegation of abuse to the Department of Public Health immediately, or within 24 hours.On 5/16/12, review of the facility Incident/Unusual Occurrence Report, dated 5/8/12, indicated that an allegation of verbal abuse occurred on 4/30/12 at 10:40 a.m. when a worksite food service technician was banging pans and raising her voice at another staff member in the presence of 11 clients.On 5/16/12 at 1:45 p.m., during an interview with Staff A, who witnessed the alleged incident, Staff A stated that she spoke to the supervisor on duty (Staff B), on 4/30/12, regarding the incident.Staff A stated, on 5/3/12, Staff B told Staff A to speak with her direct supervisor, Staff C, the Food Service Supervisor 1. Staff A stated that Staff C told her to write a report and forward it to Staff D, the Food Service Supervisor 2, which she did. On 5/5/12, Staff A stated that Staff D told her to speak with the Director of Dietetics, Staff E, and to the Assistant Director of Dietetics (Staff F). Staff A stated that, "they asked if I thought or felt it was abuse." Staff A further stated, that she "thought it was inappropriate behavior."Review of the Incident Report on 5/16/12, indicated that the alleged incident that occurred on 4/30/12 was not reported to the facility administration until 5/8/12, eight days later. The Department of Public Health was also notified of the allegation, via facility correspondence, on 5/8/12.The policy for Abuse/Mistreatment/Neglect Prevention and Reporting, # 413, effective 3/09, included the following entry under "Staff Responsibilities": "Any staff witnessing, having knowledge of, or suspecting that abuse, mistreatment, or neglect of a client has occurred shall: Immediately report to his/her supervisor. Complete an Incident Report (IR) as soon as possible and forward the IR to his/her immediate supervisor." The policy for "Incident Reporting (IR) & Investigation System," # 346, effective 7/2010, included the following entry: "When an event occurs that has an adverse effect on the safety, care, treatment, and habilitation of an individual living at [facility name] and /or the operation of [facility name], the staff are required to complete an Incident Report (IR), DS-2506, as soon as they become aware of the incident... It is required that the staff observing an incident; having first knowledge; or in all cases of abuse, "first suspicion," must begin the IR form and must complete Page 1 of the DS-2506 Form within 24 hours... When an IR is to be completed, the staff member will immediately notify their Supervisor. The Supervisor will immediately contact the Program Manager or Designee, and the Program Manager will immediately determine if the incident is to be reportable as an Incident Brief." This failure in reporting created a delay in the investigative process potentially putting all clients at risk. The violation of this regulation had a direct or immediate relationship to the health, safety, or security of patients. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009622 |
A |
12-Dec-12 |
HJ6712 |
4754 |
T22 DIV4 CH8 ART3 - 76389(a)(3) PHARMACEUTICAL SERVICES 76389(a) Pharmaceutical service shall include, but is not limited to, the following: (3) Monitoring the drug distribution system which includes ordering, dispensing and administration of medications. T22 DIV5 CH8 ART3 - 76393(a)76393(a) No drugs shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illness. The facility failed to ensure that pharmaceutical services had a system in place for monitoring the drug distribution system when the facility reported discovery of hundreds of Benadryl capsules (a sedating antihistamine) unaccounted for on the Bemis Unit and, potentially, on other residences. The pharmacy had no mechanism for tracking the use of sedating antihistamine medications. On 9/20/12 at 4 PM, the Coordinator of Nursing Services (CNS) reported to the survey team that on 9/19/12 administrative staff, while making environmental rounds on Bemis Residence at 2:40 PM, discovered emesis on the floor in a client bathroom that contained three capsules, later determined by the facility to be Benadryl (a sedating antihistamine). The CNS stated that all client records on Bemis were reviewed for any indication of unusual signs or symptoms. Client 1 was identified as having increased lethargy and no order for Benadryl. Two clients on Bemis, Clients 2 and 3, had physician orders for PRN (i.e. as needed) Benadryl. Client 4, on Bemis, had an 11 p.m. order for Benadryl to be administered daily. The initial review during facility investigation showed that the quantity of capsules remaining in the Benadryl bottle stored on the unit was inconsistent with how many should have remained based on the physician's orders and documented medication administration for Benadryl. The CNS continued that at approximately 1:30 PM on 9/20/12, during the initial investigation, staff on Bemis also made an allegation that a licensed staff may have been administering Benadryl to clients without a doctor's order. The CNS stated that all units were told to collect any stock sedating antihistamines which were to be picked up by the pharmacist and stored in the night locker. The facility reported they had also removed the alleged perpetrator from all client contact. On 9/21/12 at 4:30 PM, the survey team checked all medication carts on the residences and the day programs for any sedating over the counter medications and all had been removed. On 9/27/12 at 9:30 AM, the Chief of Pharmacy met with the survey team and explained that the facility did not track the number of Benadryl used on each unit. The pharmacist stated that they had no way to assess PRN (as needed) orders. Although each residence had a medication audit every month there was no evidence that the pharmacist inventoried over the counter stock including sedating antihistamines. On 9/28/12, during an interview, the CNS stated that the pharmacist who picked up all of the Benadryl did not document how many bottles were removed from each unit or the number of capsules left in each bottle. On 9/28/12, review of the requested pharmacy data for orders of bottles of Benadryl sent to Bemis and client specific medication documentation records on Bemis residence revealed the following: Between 6/20/12 and 9/13/12, six bottles containing 100 capsules each or totaling 600 capsules had been sent by the pharmacy to Bemis. Three clients (Clients 2, 3 and 4) on Bemis had orders for Benadryl during this period of time. Review of the Medication and Treatment Administration Records for these three clients during this same period of time indicated that only 9 capsules were administered to these clients. None of the above mentioned clients (Clients 2, 3, and 4) had orders for 75 mg of Benadryl, the amount that was observed in the emesis. When the CNS initially inspected the medication supply on 9/20/12 on Bemis, 1 bottle and 2 additional capsules were recovered. The total number of capsules accounted for were 114 capsules (including the 3 identified capsules in the emesis on 9/19/12) out of a stock of 600 delivered between 6/20/12 and 9/13/12. The facility is unable to account for 486 capsules out of 600 delivered by the pharmacy to Bemis residence, between 6/20/12 and 9/13/12. The facility's failure to have a tracking mechanism to ensure drug accountability for sedating antihistamine medications resulted in an unknown Bemis client having three 25mg Benadryl in their emesis without a physician's order for 75 mg of Benadryl and hundreds of sedating antihistamines being unaccounted for. 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. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009623 |
A |
12-Dec-12 |
HJ6712 |
14282 |
T22 DIV5 CH8 ART4-76525 (1) (20) CLIENTS RIGHTS (a) Each client has the right listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to prevent neglect by failing to implement policies and procedures (P&P) as well as the facility's plan to prevent neglect for Client 1. The facility incident management system failed to identify and remove damaged clothing protectors, potentially hazardous items, resulting in Client 1 possibly ingesting a snap and resulting in exposing 57 of 57 clients with pica (persistent ingestion of nonnutritive substances) to potential harm. The facility failed to conduct pica sweeps and environmental rounds when 309 rounds sheets, initiated between 7/1/12 - 9/22/12, indicated 101 of 309 rounds sheets did not include evidence of pica sweeps or environmental rounds. 1. Review of the facility document titled, Pica, dated December 2011, included the following definition: "Pica is the persistent ingestion of nonnutritive substances including, but not limited to: clay, dirt, sand, stones, hair, feces, lead, gloves, plastic, paper, paint chips, wood, string, cloth, metal, and/or cigarette butts." On 9/20/12, review of facility documentation was conducted. The document revealed an incident had occurred on Program 6 - Smith Unit on 8/23/2012 at 9:15 PM. The document indicated that staff found [Client 1] chewing on the snap tab end of a clothing protector (adult bib) and the staff noted that part of the snap tab was missing. The staff had not witnessed if the client had swallowed the snap tab. The Unit Supervisor (US), Staff A, was notified of the incident on 8/23/12 at 9:40 PM. The US documented a Level 1 review (an analysis of the event by the Unit Supervisor/Service Area Supervisor) dated 8/27/12, as follows: "...It is believed that the [clothing] protector had fallen off the snack cart and [Client 1] found it. When staff was able to get the clothing protector from [Client 1] it was observed that a snap was missing. Most of the protectors do have missing snaps so it is not likely that [Client 1] actually did swallow the snap ... [Client 1] could have had the clothing protector for only a very short time so it is most likely [the client] did not swallow any part of the clothing protector ...Staff will now be trained to count the number of clothing protectors going out to the floor to be sure to count them when they are done with snack time." The program director (PD) for Program 6, Staff E, documented the Level 2 review (documentation of all action taken to prevent recurrence), dated 8/28/12, as follows: "...The clothing protector had a snap missing on the tab on the collar of the [clothing] protector. It is not known if the snap had been missing prior to [Client 1] chewing on the protector, or if she chewed it off herself. Many of the clothing protectors do not have snaps intact. It is unknown if [Client 1] ingested the tab off of the snap...Clothing protectors will be accounted for before and after snack times and meals and will be checked for missing snaps..." On 9/20/12 beginning at 11:00 AM, the US, Staff A, stated that Smith Unit was home to 33 clients, 15 of whom had pica and three additional clients who chewed on cloth.Observations of the dining room on the Smith Unit revealed an unlocked cabinet with two shelves completely full of clothing protectors. Staff A and the surveyor removed 10 clothing protectors that had obvious frayed edges, loose strings, tears and loose or missing snaps. When asked how long most of the clothing protectors had been in disrepair, the US, Staff A stated, "They have always had snaps missing." When asked what system was in place to assure clothing protectors, linens and other laundry items were free of hazardous pieces, such as loose snaps, frayed edges or loose strings, Staff A stated there was no system for staff to follow. Staff A then called the laundry staff who told the Staff A that laundry staff did not check for deterioration. The US, Staff A, confirmed the facility had no system in place to assure the repair or replacement of items in disrepair. When asked if he notified anyone regarding the missing snaps, Staff A stated not until after the incident with Client 1. Staff A, the US, made no comment when asked why he had not notified anyone. Clinical record review revealed that Client 1 was admitted to the facility on 10/04/85 with profound intellectual disabilities. Additional diagnoses include Cerebral Palsy (a disorder marked by muscular impairment), Anxiety, and pica.The Staff A stated there was no Behavioral Support Plan (BSP) for pica in Client 1's record, when asked what the prevention plan related to pica was for Client 1. The US, Staff A stated, "She has lived on the Smith Unit since June 2012 without an 'open' pica plan." When asked what the staff did to prevent non-edible items from being available on the Smith Unit, Staff A stated staff conducted "pica sweeps" each shift since January 2012, after the incident with Client 2. When asked why damaged clothing protectors were still on the unit, Staff A stated he was not sure if staff were actually checking the clothing protectors for wear or just counting them. When asked why, despite pica sweeps conducted three times per day since January 2012 and weekly monitoring rounds conducted by program management, the damaged clothing protectors were not identified as a potential choking hazard, the US, Staff A stated they should have been. 2. Review of the Environmental Safety Checks dated 1/25/12 included the following directions: "Environmental rounds will be done on AM shift, PM shift and NOC [night] shift...No clothing items, attends, linen, towels, washcloths...will be left out in client areas...Staff must be vigilant and continuously monitor the area for items that can be ingested...Staff must be familiar with pica plans and should ensure implementation at all times." Review of the Pica Sweep Each Shift (Document on 24 hour log) sheet (no date) included the following directions: "1. making rounds first thing after priming as you tour the unit...4. Check for magazine and all little paper items, string, as your walking down the hallway check out the floors for small items and paper...8. When doing rounds check for broken furniture, locks doorknobs, dressers and lockers. Check equipment (wheelchairs) for broken parts..." When asked what training the Smith Unit staff had regarding environmental rounds/ pica sweeps, the US, Staff A stated staff were trained to assure equipment was in good repair. He stated he did not know if staff was checking clothing protectors as part of this sweep.During observations on 9/20/12 beginning at 1:30 PM on Roadruck Unit, the Roadruck US, Staff F and surveyor looked at the clothing protectors which were stored in an unlocked cabinet in the dining room. Eight clothing protectors with obvious tears were randomly chosen. All eight had tears and the snaps had frayed fabric surrounding them so that the snaps could easily been torn off. The US, shift lead, and IPC (Individual Program Coordinator) stated the loose strings and snaps on the clothing protectors could be a hazard. The shift lead stated, "The clothing protectors tear very easily." Staff F stated eleven clients on Roadruck Unit had pica and all were at risk for choking. Review of the Windows Orientation worksheet (information for staff working with the clients) included the names of the clients and their preferred pica items; 5 of 11 clients preferred pica items included clothing, strings, cotton, torn cloth and metal. On the Smith Unit on 9/20/12 at 6:05 PM, a review of the diet cards with directions to staff included providing clothing protectors during meals to 30 of 33 clients. 15 of 33 clients were at moderate to high risk for choking and/or had pica. During an interview on 9/20/12 beginning at 6:28 PM, when asked about the 8/23/12 incident for Client 1, the PD, Staff E stated that he asked staff to remove any clothing protectors that were missing tabs before taking them out to the floor, to count how many went out to the floor, how many came back, and to make sure all the clothing protectors were returned. Staff E stated Client 1 had a history of chewing cloth towels. When asked why the damaged clothing protectors continued to be on the Smith Unit, Staff E stated they should have been removed. On 9/26/12 at 5:20 PM, review of the Plan related to pica revealed the following under "Systemic Changes:" "Training curriculum for supervision and treatment of pica was developed. [Level of Care] LOC staff...and Central Program Services [CPS- offsite program] staff will attend this training and will complete a post-test by 8/29/12. Additionally staff assigned to Programs 4 and 6 will receive the above training for supervision and treatment of pica. Daily the shift lead will ensure Environmental Safety Checks are completed every shift. Weekly the [Client Protection Program] CPP team will review all clients identified at risk for pica to ensure systems to prevent harm are in place. Monthly the Program Risk Management team will review, analyze, and determine if the corrective actions that were developed and implemented at the weekly CPP meeting were effective for all clients identified at risk for pica." On 9/26/12, review of the sign in sheets for 7/31/12, for Policy #410, "Client Protection" included the following: "[The Facility] adheres to a practice that protects and promotes the safety of clients. A comprehensive system of client protection is in place, which provides for the thorough identification and assessment of potential risk, and immediate intervention when risk is present. The system involves a thorough investigation of all incidents that cause harm, and has a risk management process that provides for tracking, monitoring, review and analysis of incidents by Unit, occurring, track and analyze patterns and trends of incidents, develop and implement prompt and effective measures to minimize or eliminate occurrence in the future." Concurrent interview and review of the monitoring rounds conducted by program management for the months of 8/12 and 9/12 revealed many of the monitoring rounds forms were incomplete. Additionally, review of the post test for pica revealed that for the day program, "Sunrise," 8 of 8 post-tests included a section for the psychologist and unit supervisors to complete. The section was blank. Staff B stated the rounds sheets should have been completed and the post tests for "Sunrise" day program should have been completed by the psychologists and US. There were 11 units where monitoring was conducted from 7/1/12 - 9/22/12. Of 309 rounds conducted, 101 of the sheets were incomplete and did not include monitoring of pica sweeps or environmental safety. At 12:32 PM on 9/20/12, the Unit Supervisor, Staff B, for Lathrop was asked to examine each of the clothing protectors stored in unlocked cabinets in the dining room of Lathrop. Staff B examined a total of 97 clothing protectors and removed 49 of the clothing protectors due to missing snaps, holes in the material, frayed edges and other damage which compromised the integrity of the clothing protector. Staff B indicated the 49 clothing protectors were "not serviceable." The Unit Supervisor, Staff B confirmed the clothing protectors in the cabinets were available for use for the evening meal. When asked if there were other clothing protectors at Lathrop, Staff B showed the surveyor a large laundry cart full of clothing protectors in a linen storage area. After looking at some of the clothing protectors, Staff B said he would need to go through the cart and remove the damaged clothing protectors. When asked if there was a system in place to assure the clothing protects were "serviceable" prior to taking them to the dining room, Staff B said, "No." Staff B confirmed that some clients who lived at Lathrop were diagnosed with pica. 3. At 5:30 PM on 9/17/12, Client 3 was observed wearing a blue torn clothing protector while eating dinner in the Bentley dining room. At 1:15 PM on 9/20/12, the US, Staff C, for Bentley was asked to examine 9 of 9 of the clothing protectors stored in the unlocked cabinet in the Bentley dining room. Staff C examined a total of 9 clothing protectors and removed 9 of the clothing protectors due to missing snaps, holes in the material, frayed edges and other damage which compromised the integrity of the clothing protectors. Staff C stated that the facility needed a better system as these clothing protectors are thrown in the laundry and are returned as observed, shredded, torn and stained, breaking apart, and breaking down. Staff C went on to say that the facility has no system for inspecting the condition of the clothing protectors before returning them to the dining cabinets, as clean, so they would be available for use for the evening meal. 4. On 9/20/12 at 1 p.m., during an observation of clothing protectors at the Turner B offsite building, 17 clothing protectors were observed. Five of the seventeen clothing protectors were noted with multiple tears. One clothing protector snap was noted to be dangling. During concurrent interview with Staff D, Staff D acknowledged that the clothing protectors were in disrepair. The following day, on 9/21/12, a follow-up observation of the clothing protectors was conducted at the same site and 4 additional clothing protectors were noted in disrepair. Therefore, by failing to implement policies and procedures, failure to prevent neglect, and failure of the incident management system to identify and remove potentially hazardous items, damaged clothing protectors, the failures resulted in Client 1 possibly ingesting a snap and resulted in exposing 57 of 57 clients with pica to potential harm. 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. |
| 150000229 |
SONOMA DEVELOPMENTAL CENTER D/P SNF |
150009702 |
A |
03-Feb-14 |
8T7Z11 |
6233 |
T22 DIV 5 CH 3 ART 3 - 72311 (a) (2) NURSING SERVICE - GENERAL (a) Nursing service shall include, but not be limited, to the following: (2) Implementing of each patient's care plan according to methods indicated. Each patient's care shall be based on this plan.The facility failed to implement interventions per Resident 1's care plan when adequate staff was not employed during a gurney to bed transfer consistent with the resident's needs, to reduce the risk of an accident as follows: On 1/11/12, review of an incident/unusual occurrence report, dated 11/8/11, revealed that on 11/5/11 at 7:35 p.m., Staff A showered Resident 1 and returned the resident to his room on a shower gurney to transfer him back to bed. Staff A placed the gurney next to the bed and locked the wheels on the gurney. Staff A stated that Resident 1 was on his right side. Staff A lowered both side rails on the gurney and proceeded to roll Resident 1 onto his left side to make the transfer. Staff A stated it was at that time that Resident 1 rolled off the gurney and landed on the floor. The report further indicated that Resident 1 was minimally responsive and blood and cranial fluid were noted to be seeping from the resident's head. Resident 1 was transported to a community acute care hospital for diagnostic evaluation and treatment. During the record review on 1/11/12, review of an interdisciplinary noted (IDN), dated 11/5/11 at 10:30 p.m., showed that Resident 1 fell three to four feet and had landed on his left side, hitting his head.On 1/11/12, review of the community acute care hospital discharge summary, with a dictation date of 11/15/11, showed that Resident 1 was discharged from the community acute care hospital on 11/6/11 and returned to the facility. The discharge summary showed that Resident 1 had sustained a closed head injury with a "depressed fracture over the left parietal area...with some...bone fragments," and an approximate 1.5 centimeter (cm) depression. On 1/11/12, record review showed that Resident 1 returned to the facility's acute care hospital on 11/6/11, then returned to his home residence, at the facility, on 11/7/11.On 2/16/12, review of the Individual Program Plan (IPP/an assessment), dated 7/6/11, showed that Resident 1 had profound intellectual disability secondary to massive hydrocephalus and epilepsy. Resident 1 was identified as being at risk of falls/fractures/injury due to lack of hazard awareness and protective reflexes, lack of mobility, non-weight bearing status, long-term use of anticonvulsants and osteoporosis. The IPP indicated that special handling needs were required due to a massive head. Resident 1 was assessed as dependent on staff for all activities of daily living and required two familiar staff for all transfers using a transfer board or slip-sheet, one person to move the head and one to assist the resident's body. Resident 1 was bathed on a bathing trolley three times a week and his bathing routine required two staff assistance. During an interview, on 2/1/12 at 11:30 a.m., Staff D stated that Staff A did not follow Resident 1's Health Care Objectives and Plans, and that Staff A was a regular unit staff who knew Resident 1 and the care that he required. Staff D further stated that in the Interdisciplinary Note (IDN), written on 11/5/11 at 2030 (8:30 p.m.) by the Health Services Specialist (HSS), the note showed that a "transfer board slipped off the bed with one person transfer." On 2/16/12, review of Resident 1's nursing plan of care titled, "Service/Health Care Objectives and Plans," and dated 6/3/11, indicated that Resident 1 had a plan specifically designed to ensure safe transfers which read: "Sliding transfer - shower gurney: 2 staff, with 1 person to move head, 1 person to help with body." Facility policy number 410, "Client Protection & Prevention from Harm," dated January 2012, was reviewed on 2/21/12 at 2:30 p.m. Under the section titled, "Prevention/Monitoring," the policy stated that protection activities included but were not limited to: "Implementation of prevention strategies related to the assessed risk." Facility policy number 415, "Rights Assurance Program," dated October 2010, was reviewed on 2/21/12 at 2:30 p.m. Under the section of "Statement of Basic Civil and Constitutional Rights," the policy showed that a resident had "A right to enjoy personal freedom from harm under the full protection of the law, including protection from unlawful search and seizure, protection from physical injury...A right to a safe environment which includes receiving services in facilities which are physically safe..." A facility document titled, "Department of Developmental Services - Office of Protective Services," dated 1/10/12, was reviewed on 2/1/12 at 1 p.m. The document indicated that an independent investigation was completed by a Special Investigator. Under "Summary of Investigation," the Special Investigator indicated the following: Staff A reported that "while transferring (Resident 1) from the shower gurney to his bed, he fell to the ground (between the shower gurney and his bed). (Staff A) said she yelled for help and (other staff) arrived...immediately." The document showed that Staff C observed Staff B quickly going in to Resident 1's room and when he got to Resident 1's room, "he saw (Resident 1) on the floor (left side between the shower gurney and bed) and (Staff A) was at the head of the shower gurney." Under "Findings," the Special Investigator documented the following: "Based on all information gathered and reviewed, the investigation has determined that... "(Staff A failed to provide the proper care (two person transfer) for (Resident 1), when she allowed him to fall to the floor from the shower gurney. (Staff A) knew (Resident 1) was a two-person transfer and attempted to transfer (Resident 1) by herself." Therefore, the facility failed to ensure resident care was safe as indicated by the needs and plan of care of the resident and that interventions identified were implemented in order to reduce the risk of accidents. 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. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009703 |
A |
11-Feb-14 |
7FQC11 |
3729 |
Title 22-CH 8-ART 3-76363(b)(3) Food and Nutrition Services-Food Service.(b) Food services shall include: (3) Nourishment or between meal snacks shall be provided as required by the dietary plan. Bedtime nourishments shall be offered to all clients unless countermanded by the interdisciplinary team, attending physician or dietician. Title 22-CH 8-ART 3-76369(a)(1) Food and Nutrition Services-Modified Diets (a) Modified diets shall be as follows: (1) Specified by the client's interdisciplinary team with a copy in the kitchen. Title 22-CH 8-ART 3-76371 Food and Nutrition Services-Therapeutic Diets Therapeutic diets shall be provided as prescribed by the attending physician and shall be planned, prepared, and served with supervision or consultation from the dietician. Persons responsible for therapeutic diets shall have knowledge of food values in order to make appropriate substitutions when necessary. The facility failed to comply with the above regulations when facility staff failed to send a physician's order countermanding Client 1's HS (Hour of Sleep) nourishment to the kitchen so that the appropriate therapeutic diet was provided to the client. This resulted in Client 1 receiving a diet in which the client choked on the HS nourishment, requiring staff to perform abdominal thrusts to clear the client's obstructed airway. Facility documentation dated 11/29/12, revealed that on 11/28/12, Client 1 was given her designated HS dried prune snack. Staff then noticed that the client was short of breath and the client's lips became cyanotic. Staff suspected choking and initiated an abdominal thrust with finger sweep. Staff was able to extract the prune out of the client's mouth. Review of Client 1's "Client Face Sheet" on 12/12/12, revealed that the client was 48 years old with diagnoses that include dysphagia (difficulty swallowing), profound intellectual disabilities, and microcephalus (an abnormally small head and under developed brain) with motor dysfunction. Client 1's record showed that Client 1's physician wrote an order to discontinue Client 1's HS dried prunes snack on 07/13/12.Staff A stated during an interview on 12/12/12 at 4:30 p.m., that Client 1's physician's order of 7/13/12 was not sent to the kitchen, so the kitchen staff kept sending the prunes to Client 1 at HS. Staff A stated that the regular PM staff knew not to give the prunes to Client 1 but gave the prunes to another client who could tolerate them. Staff B stated during an interview on 12/12/12 at 4:35 p.m., that registry float staff passed the PM snacks on 11/28/12, and did not know that they were not to give the prunes to Client 1. Review on 12/12/12, of the facility's "General Event Reports" (GER) for the above incident, revealed that "[Client 1] had choking incident from prunes that were served to her at HS (hour of sleep) snacks. Food service had set up snacks and sticker on tray indicated that she is to get prunes. Registry staff gave her prunes according to food service tray not her diet order ..." The GER revealed that "There was a previous diet order for 3 each dried pitted prunes for HS snack; however the order was discontinued on 7/13/12. Staff failed to enter the order change in the kitchen log book or process the diet change by making necessary adjustments to the snack trays." The facility's failure to ensure that Client 1's diet order of 7/13/12 was appropriately implemented for a period of 19 1/2 weeks placed Client 1, who has a diagnosis of dysphagia, at risk of food aspiration, which occurred on 11/28/12.The facility's inaction presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009749 |
A |
08-Apr-14 |
0X8111 |
11325 |
T 22 - DIV 5 CH 8 ART 3 - 76316 (b) Developmental Program Services-Grouping Criteria(b)Clients shall be integrated with peers of comparable social and intellectual development and shall not be segregated on the basis of their handicaps unless such segregation is planned to promote the growth and development of all those grouped together.T 22 - DIV 5 CH8 ART 4 - 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.The facility failed to ensure that clients were integrated with peers of comparable social and intellectual development so as not to endanger the health and safety of the clients. When a residence (Unit B) closed on 10/16/12, twelve (12) male clients, (seven of which had severe intellectual disabilities) were moved to another residence, Unit A, with thirteen (13) higher functioning male and female clients. The facility also failed to ensure a client's right to be free from the harm/potential harm of abuse when clients, with a histories of aggression/intrusiveness towards peers and staff, did not receive effective interventions to ameliorate the immediacy or serious threat to clients/staff, when a pattern where individuals openly expressed being fearful of their living environment was not addressed so that the ongoing threats of harm was removed.Review of the ICF (Intermediate Care Facility) roster, dated 9/12, indicated that Clients 1, 3, 4, 5, & 9 had mild developmental disabilities. Clients 2, 6, & 8 had moderate developmental disabilities. Client 7 had severe developmental disabilities. On 11/30/12 at 3 p.m. and on 12/3/12 at 8:50 a.m. to 10:30 a.m., there were multiple observations of a loud and chaotic environment on Unit A and through interview and review of records, multiple clients and staff voiced fear and concerns about their safety on the unit as follows: 1. During record review on 12/7/12, an IDN (Interdisciplinary Note), dated 10/11/12 at 10:30 p.m., indicated that Client 5 heard someone banging on her door and she came out of her room screaming. The note indicated that Client 5 stated it was a peer (Client 6). The IDN also indicated that while the client was talking to staff, the same peer came out of his room staring at her. Documentation indicated that the client was visibly upset crying, "keep him away from me." "I don't want to be here no more," with tears in her eyes. Record review on 12/3/12, of a facility provided document, showed that Client 6 had recently moved from Unit B to Unit A.2. During record review, an IDN, dated 10/18/12 at 9:45 a.m. indicated, "[Client 5] told me she is afraid to live on [Unit A] because one of the new residents keeps chasing her." 3. During an interview with Client 5 on 11/30/12 at 11:30 a.m., Client 5 stated that she was frightened, as she heard her door being rattled during the night.4. On 11/30/12 at 3 p.m., loud banging was heard outside of the dining room. During concurrent interview, a staff member stated the clients were tipping the weighted chairs. At 3:10 p.m., observations revealed there were no chairs remaining in the hallway and the floor of the hallway was streaked with markings from furniture movement.5. During an interview with Staff A, on 12/3/12 at 9:30 a.m., Staff A stated that a male client (Client 7) checks other clients' bedroom doors in search of magazines. Record review on 12/3/12, of a facility provided document, showed that Client 7 had recently moved from Unit B to Unit A. 6. On 12/3/12 commencing at 8:50 a.m., the following observations were made on Unit A:a. Upon entering Unit A at 8:50 a.m. there were ongoing loud verbalizations and repetitive intrusive behaviors observed being made by a client (Client 7). Client 7 was approaching the surveyor and staff with loud vocalization which when redirected immediately resumed.b. At 8:50 a.m. staff were observed continually attempting to redirect multiple clients throughout the unit who were roaming, yelling, and displaying disruptive behavior.During a concurrent observation a client (Client 9) was observed walking with a fast pace down a hallway, repeatedly pounding the walls with his fists while staff attempted to redirect and calm him.Record review on 12/3/12, of a facility provided document, showed that Client 9 had recently moved from Unit B to Unit A. c. On 12/3/12 at approximately 9:15 a.m., there were observations of boarded up windows and walls noted in an activity room and in the Family 1 hallway. Windows in the hallway and windows on the hallway door were shattered.d. At 9:30 a.m., a female client, Client 8, was observed standing naked in the hallway, visible to male clients in the immediate area. She verbalized, in a distressed type tone that she wanted to, "take a bath." Staff intervened and provided a towel for privacy, at which time she removed the towel and sat down naked on the floor in the corner of the hallway.During an interview with Staff A on 12/3/12 at 9 a.m., the staff stated that there had been an incident of extreme property destruction by Client 1. Work orders included requests to repair/replace 10 broken windows in the north wing hallway, to replace/repair double door windows, and to replace a broken window in the family room, 131. Forms entitled, "Completed Work Order," indicated the following:1. On 12/1/12, there were exposed wires in the alarm box. 2. On 12/1/12, repairs were made to the wall that was associated with the damaged wires. Review of Client 1's IPP (Individual Program Plan), dated 9/13/12, indicated that Client 1 had diagnoses that included Impulse Control Disorder. The IPP indicated that Client 1 was on general supervision (visual and/or verbal contact no less than every 15 minutes) at home and at his worksite and constant supervision (where staff must be able to see and/or hear each client and be in close enough proximity to intervene as necessary) around female peers. During the incident of property destruction by Client 1, the client was on individual supervision (1:1) which had been implemented following an 11/29/12 incident, per interview with Staff D on 12/6/12 at 3:20 p.m. Individual supervision is defined as, staff must be able to see their assigned client at all times and be in close enough proximity to protect them and others from injury. Review of Client 1's Behavior Plans on 12/4/12 included, but were not limited to, the following: 1. Aggression: Hits, punches, kicks, spits, throws objects or scratches others. 2. Bites or attempts to bite peers or staff. 3. Property Destruction-destroys valuable property (e.g. beds, windows, TVs), throws chairs and furniture, can use items he has destroyed to harm self, kicks window in bedroom, sets fires. 4. Elopement - Bolts from supervision.On 12/4/12, review of Physician's Progress Notes, dated 10/11/12, indicated that Client 1 successfully had Clonazepam (antianxiety medication) and Quetiapine (antipsychotic medication) weaned. Further documentation indicated, "He is doing well, but is stressed by 12 clients just transferred from [Unit B]. On 12/4/12, review of Interdisciplinary Notes, dated 12/1/12 at 6:30 p.m., indicated that Client 1 became upset at the beginning of the p.m. shift because he wanted and was demanding a specific staff to provide his individual supervision. The client stormed down to Family 1 hallway into the activity room and started to engage in property destruction.Further documentation indicated that, "Client broke a table leg and started to use it like a sledgehammer and busted several window [sic], broke a plexy mirror and made holes on the walls pulling the fire alarm until wires were exposed, when staff attempted to intervene client became violent towards staff started to swing table leg at staff and was throwing broken objects to staff."The campus police were called to assist and when the police and fire department arrived, the client was able to calm down. He was given an immediate dose of Lorazepam (an anti-anxiety medication) 2 milligrams orally to help his aggression. During his escalation, he used broken plexy mirror and cut his chest, abdomen and arms, requiring first aid.On 12/4/12, review of the HSS (Health Services Specialist) note, dated 12/1/12 at 5 p.m., indicated that Client 1 sustained the following self-inflicted injuries: 1. Contusion to the middle of the forehead, 4 centimeter (cm.) x 3 cm. 2. Laceration, 7 cm. long, on the left chest above nipple line. 3. Laceration, 11 cm. long, on the left abdomen. 4. Laceration, 2 cm. long, on the left middle finger. 5. Laceration, 2 cm. long, on the left wrist. 6. Also noted was an "old" deeper laceration on the left forearm from an incident on 11/28/12.During an interview with licensed staff, Staff A, on 12/3/12 at 9 a.m., Staff A stated that she was "scared" for the first time.During an interview with licensed staff, Staff B, on 12/3/12 at 10 a.m., Staff B stated that the mixing of Unit A and Unit B was not working.On 12/3/12 at 10:30 a.m., Staff A further stated that the clients from Unit B have their routines and the clients from Unit A are not use to it, it happens, "every day." During an interview with offsite staff, Staff C, on 12/3/12 at 11 a.m., Staff C stated that since the units combined, the clients from Unit A have had increase in anxiety and the clients from Unit B do not understand boundaries. During an interview with Client 2 on 12/3/12 at 3:15 p.m., Client 2 stated that he wanted to move, "because it is dangerous here." This client asked the surveyor, three times, to be sure that the surveyor wrote his statement down.During an interview with Client 3 on 12/3/12 at 3:18 p.m., Client 3 stated that he did not feel safe on this unit.During an interview with Client 4 on 12/3/12 at 3:25 p.m., Client 4 stated that she was, "scared." Client 4 further stated that she, "did not like living here with people getting hurt." On 12/4/12, review of the facility document entitled, "General Event Report," the event summary indicated that Client 1 also broke off several table legs, broke the water fountain and chipped the tile floors when he threw the table leg to the floor.The policy for Abuse/Mistreatment/Neglect Prevention and Reporting, #413- effective 7/2012, included the following: "Abuse, mistreatment, or neglect of any person living at [the facility] is strictly prohibited." The policy further contained the definition of psychological abuse, as follows: "Any act that causes or may cause emotional distress (fear, humiliation, agitation, anxiety, confusion, depression or other negative emotional state) to a child or dependent adult; including, but not limited to threats, intimidation, or harassment."By failing to ensure that program structure met clients' individual needs and by failing to ensure a client's right to be free from the harm of abuse/potential abuse, 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. |
| 150000229 |
SONOMA DEVELOPMENTAL CENTER D/P SNF |
150009750 |
A |
06-Mar-14 |
85LY11 |
9306 |
F 309 - CFR-483.25 -Quality of CareEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.The facility failed to provide necessary care and services to attain or maintain the highest practicable physical and psychosocial well-being in accordance with a comprehensive assessment and plan of care when the facility:1. Failed to recognize and assess factors which placed a resident (Resident 1) at risk for altered wound healing by not ensuring that ongoing assessments of a wound, undergoing current treatment, were conducted; 2. Failed to ensure consistent implementation of interventions in a health care plan when observations of the wound were not documented on a daily basis, as specified; 3. Failed to consistently monitor and evaluate the resident's response to the initial treatment. Documentation referencing the wound /dressing was initiated on 7/2/12 through 7/7/12. The record lacked evidence of any further wound assessments for the next 7 days. On 7/14/12, Resident 1's right 4th finger, distal phalange, showed severe erosion down to the bone. These failures resulted in Resident 1's wound not being evaluated for seven days, a hospital admission for treatment, and subsequent surgical intervention.Record review on 7/30/12 indicated that Resident 1 had diagnoses that included cerebral palsy (a disorder of movement and muscle tone) and was at risk for skin breakdown and cellulitis (bacterial skin infection).Resident 1 had a behavior plan for self-injurious behaviors (SIB) that included hitting his head against hard surfaces, scratching himself, picking and rubbing his skin, and pulling or biting his lips, causing tissue damage.Resident 1 had a current health care plan for "Abrasions" (P-17), which included the following objective: "Will be free of skin abrasions/lesions as evidenced by the absence of redness, swelling, pain, drainage, and streaking (red lines)."Plans to meet the objectives included ..."daily... Document observations and report them as clinically indicated. daily... Observe for signs of infection: swelling, redness, drainage, presence of pain or heat. Report findings to MD/HSS (Physician/ Health Services Specialist)" and, "Notify MD/HSS if not responding to tx (treatment)." Physician's monthly orders, dated 6/16/12, included an order for Bacitracin (antibiotic) ointment to be applied to self-injurious behavior lesions/abrasions prn (as needed) each shift, and Povidone Iodine 10% (percent) ointment (antiseptic) to be administered twice per day to abrasions with appropriate dressings, if needed.On 7/30/12, review of "Interdisciplinary Notes" (IDNs), dated 7/2/12 at 12 noon, indicated that Resident 1 received APAP /Hydrocodone (pain medication) for outward signs of pain /discomfort by proxy, 4/10 (pain scale with 10 being the worst pain), at 9:45 a.m. The notes showed that Resident 1 "displays grimacing, SIB evidence [sic] by hitting self in the head, face, forehead, and ears. [Resident 1] was picking and rubbing hands/fingers..." The HSS had been notified.Interdisciplinary Notes, dated 7/2/12 at 12:50 p.m., indicated, "HSS notified an abrasion on r (right) ring finger approx. (approximately) 1 cm (centimeter) x 0.5 cm circular abrasion due to witnessed SIB. Povidone-Iodine and bacitracin applied and covered with Kerlix [gauze dressing]. Will continue to observe."Daily entries in the Interdisciplinary Notes from 7/2/12 through 7/7/12, that related to the wound, were as follows: 7/2/12 at 4 p.m. - "(R) [right] ring finger abrasion tx (treatment) applied." 7/3/12 at 6 a.m. - "R finger covered."7/3/12 at 2 p.m. - "R ring finger abrasion dry, no bleeding, remains open. Povidone-Iodine applied and bacitracin dressing changed." 7/3/12 at 10 p.m. - "R ring finger tx (treatment) applied drsg (dressing) intact." 7/4/12 at 5 a.m. "R ring finger dressing intact. No sign of pain. Will continue to monitor."7/5/12 at 6 a.m. - "R ring finger dressing dry and intact." 7/5/12 at 2:30 p.m. - "R ring finger abrasion still noted, dry, without bleeding noted." 7/5/12 7:20 p.m. - "R ring finger abrasion healing slowly." 7/6/12 at 6 a.m. - "R ring finger no bleeding noted." 7/6/12 at 2:30 p.m. - "R ring finger abrasion healing." 7/6/12 at 9:30 p.m. -"L [sic] ring finger is healing. sm. (small) dry scab in place." 7/7/12 at 6:10 a.m. - "R ring finger covered and kept dry." 7/7/12 at 9:30 p.m. - "R ring finger healing slowly." After the above entry on 7/7/12, the record lacked evidence of any further documentation of a wound assessment, description of the wound, or response to treatment until seven days later when the wound was observed by an HSS on 7/14/12 at 7:30 a.m., at which time a TC (Temporary Condition) was initiated. The TC indicated, "During my nursing assessment for pressure wound on the coccyx, I became more involved addressing other skin issues. As I was evaluating and treating those, a NOC (night) shift staff asked me to check dressing on the client's right 4th finger. When I opened the gauze dressing, I noticed severe erosion on the distal joint of the finger and asked MOD [Dr. A] to exam [sic] the client. IDN recorded on the 7/2/12 about 1.5x 0.5 cm (centimeter) skin abrasion on the right 4th finger. Staff observed SIB at that morning and treated the abrasion with iodine and bacitracin ointment. Dressing was changed one more time on the next day but no follow ups since then." Objective findings included: "Severe erosion on the distal joint of the Right 4th finger. The distal finger joint is almost gone and only flappy fingernail bed remains." The client was seen by the MOD.Physician's Progress Notes, dated 7/14/12 at 7:30 a.m., indicated the following: "Just brought to my attention this a.m. Tip of 4th finger distal phalange shows severe erosion down to the bone without any purulence around [unable to read] of fingertip. This will require surgical consultation.Imp: (Impression) - [unable to read] R. 4th finger probable osteomyelitis.Plan: To ER [name of outside hospital] for surgical consultation." Review of the Emergency Room Report, dated 7/14/12, indicated, "Impression... Mangled right ring finger, self-injurious behavior." The x-ray report of the right ring finger, dated 7/14/12, indicated, "Soft tissue avulsion [a forcible tearing away or separation of a bodily structure or part] with probable underlying bony injury, distal phalanx (finger bone) of the fourth digit."The Admitting History and Physical documentation, dated 7/15/12, indicated: "I saw him the morning of 7/14/12 where he was noted to have a large avulsion fracture with bone exposed and high risk of infection... Cultures were taken. He was started on Vancomycin (an antibiotic) as a precaution and also as a preoperative antibiotic...Assessment: Somewhat of a degloving (section of skin is torn off underlying tissue, severing the blood supply) type injury to the tip of the finger with bone exposed."The Operative Report, dated 7/15/12, indicated the procedure performed was Osteotomy (bone cutting) of distal phalanx, removal of bone, debridement and V-Y plasty (surgical method for lengthening tissue), skin coverage to the right ring finger.Physician's Progress Notes, dated 7/15/12 at 4:30 p.m., indicated that Resident 1 returned to the facility's GAC (general acute care) on intra-venous Vancomycin and Cipro (antibiotics).Resident 1 returned to his unit on 7/20/12.The facility IR (Incident Report) Level 111, signed on 7/20/12, indicated on 7/2/12 there was no IDN from an HSS noting that they had examined the resident's finger. Further documentation indicated that Resident 1 was seen eight times by an HSS but none of their notes indicated that they had examined/checked the status of the client's right 4th finger until 7/14/12 when the HSS reported the severe erosion to his finger.On 7/30/12 at 11:45 a.m., when asked about the lack of continuity with assessment, the Unit Supervisor, Staff B, stated, "It didn't get followed."During an interview with Staff C on 11/27/12 at 12:15 p.m., Staff C stated that she had noticed the abrasion on Resident 1's finger and that he had a standing order for treatment. She stated that four staff were present, including an HSS, as the client was highly agitated while applying the dressing to his finger.During an interview with administrative staff, Staff D, on 11/27/12 at 1:30 p.m., Staff D was asked about the protocol for utilizing the HSS log and opening a Temporary Condition. Staff D stated that, "Every little abrasion isn't logged, not something tiny. It's not expected to be on the log." Staff D further stated that a Temporary Condition would not have had to been opened because the Resident had a standing order and a health care plan.Therefore, the facility's failure to provide an ongoing assessment for a wound with a "high risk of infection," along with lack of implementation of the health care plan resulted in a delay in treatment necessitating hospitalization and surgical intervention.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. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009861 |
A |
02-Apr-14 |
1Z9R11 |
7928 |
T-22 DIV 5 CH 8 ART 3 76315 (b)Developmental Program Services - Individual Program Plan (b) The individual program plan shall be implemented as written. T22 DIV 5 CH 8 ART 4 76525 (a) (20) Clients' Rights (a) Each client has the rights listed in (a) of the section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights:(20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to protect Client 1 from harm and neglect when staff failed to provide constant supervision (staff must be able to see and/or hear him and be in close enough proximity to intervene when necessary) when Client 1 was off of the unit which resulted in Client 1 ingesting a bottle of hand sanitizer and a bottle of rubbing alcohol and the facility failed to implement Client 1's IPP (Individual Program Plan) as the IPP identified alcohol poisoning as a risk due to Client 1's behavior which was addressed in Client 1's Behavior Plan.Client 1's medical record was reviewed and indicated that Client 1 had multiple diagnoses that included profound intellectual disability and autism (failure to relate in the ordinary way to people and situations and by repetitive activities, developmental language disorders and inability to adjust socially). The facility document titled, "IPP" (Individual Program Plan) dated 12/12/12, revealed under Section P5-2 Alcohol Dependency that Client 1 had a history of abusing alcohol and that he was at risk for alcohol poisoning and that Client 1 could be very cunning at his attempts at procuring alcohol. His persistent interest in alcohol was a serious risk. The facility document titled, "Psychological Evaluation," dated 12/17/12, revealed that Client 1 drank a potentially fatal amount of alcohol in 2002 which resulted in a coma for more than one day. The facility document titled, "Behavior Support Plan," (BSP) dated 3/28/13, revealed that Client 1 had an open plan for PICA (attempts to ingest inedible items including alcohol-based products) and was at risk for ingestion of life-threatening amounts of alcohol which heightened the risk of injury during an elopement. The primary sources of alcohol had been hand sanitizers and alcoholic beverages. The BSP indicated that Client 1 required constant supervision when off of the unit. Facility policy number NC227 PICA, dated December 2011, was reviewed. The policy indicated... "When a client has a PICA condition, LOC (level of care) staff will monitor client per level of supervision." Facility policy number 460 Supervision of Clients, dated January 2012, was reviewed. The policy indicated..."Constant Supervision: Staff must be able to see and/or hear each client and be in close enough proximity to intervene as necessary." Facility document titled "General Events Report," dated 4/16/13, was reviewed. The document indicated that Client 1 was working with his mobile crew on 4/16/13 loading the trailer with paper from different buildings, on their daily scheduled route. The clients' van was parked outside of the lab. The lab staff documented that a client was in the lab and was going from one room over to another room. The client was holding a bottle of hand sanitizer. The lab staff observed the client throw the bottle of hand sanitizer into the trash. The client picked up a bottle of rubbing alcohol and appeared to be drinking from it. The lab staff intervened and took the bottle of alcohol from him, at which time the client ran off. On 4/17/13, at 1:05 p.m., Staff A was interviewed. Staff A stated, "I was walking down the hall in the lab around 10:45 a.m. and saw a client going from one room to another room. He was holding a bottle of hand sanitizer in his hand. When he saw me, he threw the bottle in the garbage. When I checked the bottle, it was empty. The hand sanitizer bottle is an eight ounce bottle. It was half full prior to him taking it. He drank at least four ounces of hand sanitizer." During a concurrent interview with Staff B, Staff B stated, "About the same time after my staff saw the client with the hand sanitizer, I heard a noise down the hall near the lab draw area. I went down to see what was going on. I observed the same client with a bottle of rubbing alcohol in his hand and it appeared that he was drinking it. I immediately intervened and took the bottle from him. At that point, the client ran out the back door. The client was alone. I did not see any other staff with him. The 16 ounce bottle of rubbing alcohol was half to three quarters full before the client took it. I looked at the bottle after I had removed it from his hand, and there were only about one to two ounces of alcohol left in the bottle. I started to look for the client outside and noticed that he was sitting in a van with other clients parked behind a building not far from the lab. I told the van staff what had happened. The van staff opened the van door and I identified the client that had been in the lab." Staff B continued to state that the rubbing alcohol was kept on a cart in a separate room for staff to use for blood draws and the hand sanitizer was kept on a tray in another room for staff to take on the units to do blood draws. Staff B stated, "The doors to these two rooms are not locked, as staff go in and out of them frequently for lab procedures." Review of the facility "Emergent/Non-Emergent Community Hospital Transfer," record dated 4/16/13, showed that Client 1 had "ETOH (alcohol) on breath" and decreased level of consciousness. A "(Community) Fire & Rescue Authority Prehospital Patient Field Notes" form dated 4/16/13 described Client 1 as "very diaphoretic (perspiring greatly) on scene. Opens eyes to voice only...New abrasion/hematoma above (left) eye and abrasions to both knees. Some blood in nares (nostrils) as well." Review of the "Emergency Provider Record" from the local community hospital emergency room (ER), dated 4/16/13, described the client's decreased mental status upon admission to the ER at 12:51 p.m. as "obtunded" (decreased alertness, slow responses and sleepiness) with a "roving gaze." The client was held for observation prior to discharge at approximately 3:35 p.m., the documentation showed an alcohol level of 0.022.On 4/17/13, at 2 p.m., Staff C was interviewed. Staff C stated that Client 1 had a history of alcohol seeking behavior. Staff C stated, "The client is an opportunist and a deep thinker. If he notices an opportunity to take any substance which is alcohol based, he will wait until the right time to take the item. He should never be left alone when he is off of the unit. His supervision level is constant (staff must be able to see and/or hear him and be in close enough proximity to intervene when necessary)." On 4/19/13, at 1:30 p.m., Staff D was interviewed. Staff D stated, "I admit, I am guilty. I was not watching the client. I was too busy helping other clients and he was out of my line of sight. His level of supervision is constant supervision and I did not provide this for him." The facility failed to protect Client 1 from harm and neglect when staff failed to provide constant supervision (staff must be able to see and/or hear him and be in close enough proximity to intervene when necessary) when Client 1 was off of the unit which resulted in Client 1 ingesting a bottle of hand sanitizer and a bottle of rubbing alcohol and the facility failed to implement Client 1's IPP (Individual Program Plan) as the IPP identified alcohol poisoning as a risk due to Client 1's behavior which was addressed in Client 1's Behavior Plan. These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009862 |
B |
14-Mar-14 |
PQMO11 |
2478 |
T22 DIV5 CH8 ART4 76525 (a)(14) 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: (14) To dignity, privacy, respect and humane care, including privacy in treatment and in care for personal needs. The facility failed to implement policies and procedures when it failed to provide a client (Client 1) with dignity and privacy, by administering oral medications to the client while that client was on the toilet. On 4/25/13 at 3:37 p.m., a review of Client 1's "IPP NARRATIVE" (Individual Program Plan Narrative) dated 9/26/12, indicated that Client 1 was a 57 year-old male with diagnoses of profound intellectual disability and autism. Client 1 would respond when staff initiated interaction with him, and he would respond to praise and positive attention. During medication pass, on 4/24/13 at 8:15 a.m., Psychiatric Technician A (PT A) entered Client 1's room holding a medication cup in her hand. Client 1 was sitting on the toilet in a bathroom attached to the client's bedroom. PT A walked directly into the bathroom without pausing and administered the medication to Client 1, who remained on the toilet. During an interview on 4/24/13 at 12:50 p.m., PT A stated that giving medications to Client 1 while he was on the toilet was a "judgment call," since the medications had already been prepared for administration. PT A stated that Client 1 was known to spend a long time on the toilet, and PT A wanted to be certain that Client 1 received his medicine before leaving for the day program. PT A stated she knew this was a dignity issue. A review on 5/2/13 of the facility's "RIGHTS ASSURANCE PROGRAM 415" policy and procedure (dated October 2010), indicated that it is the responsibility of every person who provides services to clients of [facility name] to ensure that all clients have the opportunity to enhance their wellbeing, preserve their human dignity, and be respected as citizens. The facility failed to implement their policies and procedures to protect client's rights to dignity and privacy when PT A gave Client 1 his medications while on the toilet. These failures caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to clients. |
| 150000229 |
SONOMA DEVELOPMENTAL CENTER D/P SNF |
150009935 |
B |
14-Mar-14 |
ZF5311 |
3027 |
Health and Safety Code Div. 2. Licensing Provisions Chapter 2.4 - Quality of Long-Term Health Facilities 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.On 3/29/13 at 10:52 a.m., the Department received written notification that on 2/15/13 two residents (Resident 1, Resident 2) were found in urine soaked bed linens and that neither resident had been repositioned all night. The notification reported that the Unit Supervisor had found both residents in this condition after the night shift - a.m. shift rounds, "suggesting that the two clients [residents] had not been repositioned or had their incontinent briefs changed on the NOC [night] shift as required." The facility's failure to notify the Department impeded the ability of the Department to investigate this allegation in a timely manner, potentially exposing the residents to risk of repeated neglect. According to the facility's notification, the nurse responsible for caring for the two residents continued to work in the facility after the 2/15/13 incident, until 3/15/13, when that nurse took a leave of absence due to illness, potentially placing those and other residents at risk of neglect during that period of time. It was not until 3/28/13, forty-two days after the incident, that the facility contacted and advised the nurse that she was placed on administrative reassignment with no resident contact. It was one day later, on 3/29/13 that the facility notified the Department.Review of Resident 1's record on 3/29/13, included an "Individual Plan Treatment Profile," dated 12/19/12, which showed that the resident was diagnosed with quadriplegia (paralysis of both arms and legs). Resident 1's "Service/Health Care Objectives and Plans," (undated) showed that the resident relied on staff to be positioned and turned when in bed. Review of Resident 2's record on 3/29/13, which included a "Nursing Evaluation Assessment," (undated) showed that the resident was totally dependent on staff for all activities of daily living." A "Service/Health Care Objectives and Plans," (undated), for the resident, showed that Resident 2 was diagnosed with quadriplegia. During interview of a unit supervisor (US A) on 3/29/13 at 2 p.m., the unit supervisor stated that the reason for not reporting immediately was that US A was gathering more information about the nurse responsible for the care of Residents' 1 and 2 at the time of the incident, as that particular nurse was still in a probationary period. US A stated, "I know now that I should have reported right away and not waited until the 28th." Failing to report the incident of suspected neglect of the two residents, Resident 1 and Resident 2, to the Department immediately or within 24 hours had a direct or immediate relationship to patient health, safety, or security. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150009937 |
B |
02-Apr-14 |
O4Y111 |
4328 |
T 22 CH 8 ART 4 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. The facility failed to protect Client 1 from harm and neglect when staff failed to provide close supervision (staff must be in the immediate area and must make visual contact every five minutes) which resulted in Client 1 leaving his room, climbing over a peer's bedroom wall and obtaining a bottle of alcohol-based hand sanitizer. Review of Client 1's chart revealed that he was a 57 year old male with diagnoses that included profound intellectual disability and autism (abnormal introversion and egocentricity; acceptance of fantasy rather than reality). He had a history of alcohol abuse, alcohol-seeking elopement, and ingesting alcohol-based hand sanitizers. During an elopement, Client 1 was at risk for ingestion of life-threatening amounts of alcohol. He was fully ambulatory with a steady gait and balance. He was able to climb over walls and fences easily. He was a large man and able to bolt from his living unit or group. He was essentially non-verbal, however communicated with a limited vocabulary and used gestures. He was capable of understanding what was said to him. On 4/17/13, Client 1 was involved in a day program activity with his worksite program. Staff failed to provide Client 1with close supervision (Staff must be in the immediate area, hear the client at all times, and must make visual contact at least every 5 minutes) while he was off of the unit. Client 1 left the group unattended. He entered the facility lab and obtained a bottle of hand sanitizer and a bottle of rubbing alcohol which he ingested. The facility document titled, "Psychological Evaluation" dated 12/17/12 revealed that Client 1 drank a potentially fatal amount of alcohol in 2002 which resulted in a coma for more than one day. The facility document titled, "IPP (Individual Program Plan) Narrative" dated 12/18/12, revealed under Section P5-2 Alcohol Dependency that Client 1 had a history of abusing alcohol and that he was at risk for alcohol poisoning. The facility document titled, "Behavior Support Plan" dated 5/16/13 revealed that Client 1 was at risk for ingestion of life-threatening amounts of alcohol and his primary sources of alcohol had been hand sanitizers and alcoholic beverages. No hand sanitizers with alcohol were allowed on the Corcoran Unit. If alcohol-based sanitizers were found on the unit, they were to be removed from the area, secured and the supervisor was to be notified. A General Events Report (GER), dated 5/14/13, was reviewed. The GER revealed that on 5/14/13 staff was alerted to Client 1exiting his room when his door alarm sounded. Staff was not able to locate Client 1 in the immediate area but followed the noises coming from a peer's room. When staff entered the peer's room, Client 1 was observed to be standing there. Upon seeing staff, Client 1 then jumped over an approximate seven foot wall which separated the living quarters from each peer. Staff immediately entered the next room and observed Client 1 holding a bottle of alcohol-based hand sanitizer. On 5/16/13 during interview, Staff A stated, "Even though we have put an alarm on the client's door frame to alert staff if he leaves his room, and the assigned staff to supervise him wears a door alarm pager on his/her belt, and we do every five minute checks according to his behavior plan, he was still able to get away from us. Somehow our system for providing adequate supervision for him broke. This should not have happened." The facility failed to protect Client 1 from harm and neglect when staff failed to provide close supervision (staff must be in the immediate area and must make visual contact every five minutes) which resulted in Client 1 leaving his room, climbing over a peer's bedroom wall and obtaining a bottle of alcohol-based hand sanitizer. These violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 150000229 |
SONOMA DEVELOPMENTAL CENTER D/P SNF |
150010016 |
A |
10-Apr-14 |
3TKR11 |
8930 |
F333 - CFR 483.25(m)(2) Residents are free of any significant medication errors. F425 - CFR 483.60(a)(b)(1) Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.75(h) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who- (1) Provides consultation on all aspects of the provision of pharmacy services in the facility; The above regulations were violated when the facility failed to ensure that: (1) the facility pharmacy filled the physician's prescription for oral morphine correctly; (2) licensed staff identified wrong medication dispensed to the unit; (3) failed to ensure that Resident 1 was administered the correct medication (morphine a short-acting narcotic) as prescribed and instead administered methadone, (a long acting narcotic). These failures resulted in the resident's emergent transfer and admission to a community hospital for respiratory failure. Resident 1 was a 59 year old, dependent on staff for all activities of daily living. The resident had a history of chronic obstructive pulmonary disease (chronic lung disease that restricts airflow), with recurrent aspiration (the taking of foreign matter into the lungs with the respiratory current) and received all medication and nutrition via a stomach feeding tube. Resident 1 was prescribed medications and routine breathing treatments for this chronic respiratory condition, as well as periodic morphine 10 milligrams oral solution ordered for pain.Resident 1 died on 6/8/13. On 6/12/13 the resident's medications were returned to the pharmacy by the facility Office of Police Services (OPS), at which time the discovery was made by the receiving pharmacist, that the package had two labels: one label for morphine 5 mg. per 0.25 milliliters, and the other label for methadone 2.5 mg. per 0.25 milliliters. The syringes for oral dosing, inside the package were all labeled "methadone 2.5 mg. per 0.25 milliliter" and not morphine as prescribed by the physician.The pharmacy document titled, "Control Sheet," for the prescribed morphine (which accompanied dispensed medication) had the tracking number 1353. The tracking number on each of the two labels on the package was also 1353. However one label identified the medication as morphine and the other label as methadone.Nursing Progress notes dated 6/1/13 at 9:40 p.m., indicated that Licensed Staff called the Health Services Specialist (HSS) at 8:10 p.m., because Resident 1 had "poor vital signs and was not looking well." The HSS noted the resident was cool with raspy respirations and suctioned a large amount of thick, brown phlegm. The resident continued to receive respiratory treatment and oxygen and the physician was notified and came to assess the resident.The nursing note and the Medication Treatment Record (MTR: the nursing document used to indicate administration of the dose and time a medication was given), indicated that at 10:30 p.m., Staff A, administered morphine 10 mg. via the resident's gastrostomy (stomach feeding tube). However, the syringes of oral solution administered, actually contained and were labeled methadone 2.5 mg per 0.25 ml's each. The resident received 10 mg. of methadone instead of morphine.Nursing progress notes indicated that at 1:30 a.m., on 6/2/13 staff notified emergency personnel upon observing the resident's color change and need for respiratory assistance. The resident was transferred via ambulance to the local community hospital. Review of the Emergency Room Report dated 6/2/13, documented: "Per paramedic report, the patient was found to be with significantly depressed respirations at 3 to 4 per minute... She was given Narcan at 2mg IV (intravenous) in the field with immediate improvement. The pupils became equal, round and reactive. Respiratory status improved." The resident was admitted with "apparent narcotic overdose, accidental with secondary aspiration..." The community hospital discharge summary dated 6/5/13 indicated the resident's discharge diagnoses as aspiration pneumonia, respiratory failure, acute and chronic and urinary tract infection.The resident was discharged back to the facility's acute hospital on 6/5/13 and died on 6/8/13.During an interview on 6/28/13 at 11 a.m., the Unit Supervisor (U.S.) stated that when she picked up the medication from the pharmacy on 5/28/13 she counted the syringes and checked the control number but overlooked the drug name on the label. The U.S. further stated that the licensed staff and she had discussed the dosage on the labels and thought it was confusing.During an interview on 6/28/13 at 2 p.m., Pharmacist A verified that the error was not picked up until the medication was returned to the pharmacy on 6/12/13. He stated "it definitely got missed by a lot of eyes." The system of distributing narcotic oral solution via pre-filled syringes had just been initiated 5/3/13. Packages of pre-filled methadone and morphine had been stored right next to each other at that time. The packages were labeled by the pharmacy technician and verified by the pharmacist on duty.During an interview on 7/11/13 at 3 p.m., Pharmacist B stated that a pharmacist pre-filled and labeled the syringes. The technician would have obtained the control document and placed that label on the bag. The pharmacist always verifies the order before it goes out. Pharmacist B stated that it was his responsibility to catch a mistake and he didn't catch it. The pharmacist stated that he felt very badly.During an interview on 6/28/13 Licensed Staff A stated that the R.N. and the Psychiatric Technician both checked the dosage and double checked the orders. Staff was at a loss to explain how the conflicting labels on the package and on the syringe was missed by so many staff.The resident had Physician's orders for 10 mg of oral morphine every two hours as needed for pain. Review of the resident's monthly Medication Treatment Record, indicated that the resident's usual dose when needed was 10 mg. of morphine in a 24 hour period. Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain Sixth Edition (2008) published by the American Pain Society, documented on page 27 Table 4 titled: "Guidelines for Methadone Administration" that: "If the total morphine or equivalent dose per day is less than 90 mg (oral), a methadone dose ratio of 1:4 (methadone to morphine) is used..." Therefore a 2.5 mg. dose of methadone would be considered to be equivalent to 10 mg. of morphine for Resident 1. The resident received 10 mg. methadone four times the recommended dose, in error.Review of the package insert for methadone (which is the Food and Drug Administration approved product labeling for a medication), obtained from "Daily Med" at the National Library of Medicine, National Institute of Health website, contained the following risk under Section 5 subsection 5.2 titled Warnings and Precautions: "5.2 Life-Threatening Respiratory Depression. Respiratory depression is the primary risk of methadone. Respiratory depression, if not immediately recognized and treated, may lead to respiratory arrest and death. Respiratory depression from opioids is manifested by a reduced urge to breathe and a decreased rate of respiration, often associated with a "sighing" pattern of breathing (deep breaths separated by abnormally long pauses)." And the same package insert under subsection 5.6: "Use in Patients with Chronic Pulmonary Disease. Monitor patients with significant chronic obstructive pulmonary disease... particularly when initiating therapy and titrating (see below) with methadone, as in these patients, even usual therapeutic doses of methadone may decrease respiratory drive to the point of apnea [see Warnings and Precautions (5.2)]. Consider the use of alternative non-opioid analgesics in these patients if possible." Titration means the smallest amount of a reagent of known concentration required to bring about a given effect.In summary, failure of the facility to dispense and administer the correct medication (morphine) as ordered by the physician, and to instead dispense and administer methadone, to Resident 1, who had a history of respiratory compromise, resulted in the hospitalization of the resident, in respiratory distress. The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result for Resident 1. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150010135 |
A |
21-Mar-14 |
7JRT11 |
9263 |
T 22 DIV5 CH 8 ART 4 - 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 orisolation, excessive medication, abuse or neglect. The facility failed to ensure that five clients were free from immediate threat to their safety and failed to prevent harm from an assaultive client when: 1) staff did not implement Client 1's written individual program plan for providing individual supervision (staff must be able to see their assigned client at all times and be in close enough proximity to protect them and others from injury and staff must not leave the client unattended at any time or be distracted by other issues) and, 2) staff did not immediately intervene when Client 1 exhibited precursor behaviors prior to harming others which resulted in five peers that were injured by Client 1. Review of Client 1's record revealed that he was a 30 year old male with multiple diagnoses that included moderate intellectual disability disorder, autism (failure to relate in the ordinary way to people and situations and by repetitive activities, developmental language disorders and inability to adjust socially), intermittent explosive disorder (marked by alternating periods of hyperactivity and inactivity) and post-traumatic stress disorder (a reaction to traumatic or catastrophic event- examples of symptoms include anger, depression, and rage). He had a history of aggressive and destructive behaviors which included pinching, scratching, hitting and pushing others. Client 1 was ambulatory, a large man and capable of moving quickly towards others. He was non-verbal, however communicated through body language and gestures.A General Event Report (GER) was reviewed on 6/21/13. The GER indicated that on 1/20/13 at 5 p.m., Client 1 was coming into the hallway of his home unit. Client 2 was standing in the hallway. Without any visible antecedents, Client 1 pushed Client 2. Client 2 fell to the floor hitting his head. Client 2 sustained a contusion to his forehead and bleeding was noted from his left nostril. A General Event Report (GER) was reviewed on 6/21/13. The GER indicated on 2/22/13 at 6:10 p.m., Client 1 was being escorted from the dining room by a staff person. Without any visible antecedents, Client 1 ran ahead of his staff escort and pushed Client 3 from the back. Client 3 fell and hit his head on the floor. Client 3 sustained a laceration to his head. A General Event Report (GER) was reviewed on 7/23/13. The GER indicated on 3/8/2013 at 5:30 p.m., during a group activity Client 2 left the group area to use the restroom. Client 1 stood up and pushed Client 2 without warning. Client 2 fell, face-down onto the floor which resulted in a jagged deep laceration to the bridge of his nose and fractured nose. Client 2 was transferred to an acute hospital for treatment. A General Event Report (GER) was reviewed on 7/23/13. The GER indicated on 6/19/13 at 4:40 p.m., Client 4 and several other peers were on a community outing. During the van ride, Client 1 became agitated and assaulted the staff sitting next to him and Client 4 who was seated in front of him. Client 4 sustained scratches on his face, neck and upper back and a bruised area on his back. A General Event Report (GER) was reviewed on 7/26/13. The GER indicated on 7/19/13 at 10:15 a.m., during a day activity at worksite, Client 5 began socializing with loud vocalizations. Client 1 became upset, stood up from his activity and walked towards Client 5 and pushed her in the back. Client 5 fell to the floor and landed on her left knee and left elbow. She sustained an abrasion to the left knee and a bruised area on her left elbow. A General Event Report (GER) was reviewed on 7/26/13. The GER indicated on 7/19/13 at 4:50 p.m., Client 1was sitting outside next to his 1:1 staff (staff must be able to see their assigned client at all times and be in close enough proximity to protect them and others from injury. Staff must not leave client unattended at any time or be distracted by other issues) person. Client 1 stood up from his chair and without warning he stepped towards Client 6 who was also outside, and pushed him down without any provocation. Client 6 fell into the grass and dirt area. He sustained an abrasion above his left eyebrow area. The GER also revealed that, "...This is the second time which this client has pushed a peer today." On 6/24/13, at 1 p.m., during interview Staff A stated that the team had met multiple times to address Client 1's "serial pushing." Staff A stated, "We have met to discuss new preventative strategies to hopefully prevent him from injuring his peers. He has a long history of assaults on his peers. Staff needs to have heightened awareness of his potential to harm others. Staff needs to monitor him closely and keep him away from his peers. If he thinks that he is being crowded, he will assault. He is young, strong and fast and can definitely hurt others. Sometimes there are no antecedents prior to his assaulting a peer. Staff needs to watch him constantly." On 7/23/13, at 12:30 p.m., during interview, Staff B stated, "I have done a timeline on his aggressive behaviors - there is a pattern developing. I have addressed this issue with staff on the Bemis Unit and I believe that active treatment is not being provided for him like it should be which is possibly resulting in his aggression to his peers." On 7/23/13, at 2 p.m., during interview Staff C stated, "The client is having problems because he was moved from his previous unit which closed into a more crowded environment on the Bemis Unit. We are constantly changing his meds to prevent his aggression toward other clients. We have not found the right medication yet and he is taking out his frustrations by attacking other clients. He is a challenge. He was on a 1:1 supervision level with one staff on the day shift and evening shift for a long time. However, a 1:1 staff person is very expensive. He is now on a 1:1 supervision level on the evening shift only. Staff needs to watch him closely. He is a big guy and he is very fast." On 7/25/13, at 2:15 p.m., during interview Staff D stated, "Staff needs more training on how to care for this client and monitor him properly. For example, I don't understand why a small framed female staff was assigned to monitor this big, fast client when he was outside. The end result was that the client injured a peer and there is nothing that she could have physically done to prevent the assault. Another problem is that this client's 1:1 staff person was stopped on the day shift and only continued on the evening shift. I think that the staff is more of a challenge than this client. Staff needs to be more appropriate with him and not trust him when he stands up to move to another area. This is the time he will probably assault a peer. Staff is not providing good supervision for him and protecting the other clients. Staff is aware that all this information is in his behavior plan and they are not following it very well and the end result is that peers are being injured." The facility document titled, "Individual Program Plan" (IPP) dated 3/2/12 reviewed on 6/24/13 revealed that Client 1's self- injurious behaviors pose a risk of injury to himself and his assaultive behaviors pose a risk to harm others. The facility document titled "Behavior Objectives and Plans" dated 7/11/13 reviewed on 6/24/13 revealed the following: 1. Client 1 - target behavior is aggression, resulting in pinching, scratching, hitting and pushing peers and/or staff. 2. Precursor behaviors: Getting up from his chair and moving quickly towards peers (pushing) and reaching toward others (pinching, scratching and/or hitting). 3. Preventative Strategies: Staff is to seat Client 1 away from peers in a group setting so that he is less likely to push them and if Client 1 begins to exhibit precursor behaviors, staff is to immediately intervene and attempt to redirect him. 4. Guidelines for Individual Supervision: Individual supervision is to be provided at all times to prevent him from harming others. The facility failed to ensure that clients were free from immediate threat to their safety and failed to prevent harm from an assaultive client when: 1) staff did not implement Client 1's written behavior program plan for providing individual supervision (Staff must be able to see their assigned client at all times and be in close enough proximity to protect them and others from injury and staff must not leave the client unattended at any time or be distracted by other issues) and, 2) to immediately intervene when Client 1 exhibited precursor behaviors (getting up from his chair and moving quickly toward a peer and reaching toward a peer) to prevent harming others which resulted in 5 peers being injured by Client 1. These violations presented risk that either imminent danger or serious harm would result or a substantial probability that death or serious harm would result. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150010136 |
B |
21-Mar-14 |
EVU711 |
9312 |
T22 - DIV5 CH 8 ART 4 - 76525 CLIENTS? RIGHTS (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect.The facility failed to ensure that four clients were protected from immediate threat to their safety and failed to prevent harm from a client with identified assaultive behaviors when: 1) staff did not provide sufficient supervision for Client 1, and 2) staff failed to immediately intervene when Client 1 exhibited precursor behaviors which included running down the hallway, tapping walls excessively, screaming, agitation, restlessness and banging on walls prior to harming others which resulted in four peers being assaulted by Client 1. Review of Client 1?s record revealed that he was a 27 year old male with multiple diagnoses that included moderate intellectual disability and bipolar disorder. He had a history of aggressive, assaultive behaviors (hitting, kicking and pushing others to the floor) and manic (disordered mental state of extreme excitement) behavior. Client 1 was ambulated independently.He had good balance and gait and ran very quickly. Client 1 preferred to pace and run quickly down the unit?s halls, pushing peers out of his way. He was nonverbal however communicated through vocalizations and gestures. A General Event Report (GER) was reviewed on 7/15/13. The GER indicated on 3/28/13 at 3:50 p.m., Client 2 was in the hallway and Client 1 was pacing back and forth (a precursor behavior) in the same area where Client 2 lived. Staff opened the dining room door and observed Client 1 push Client 2 against the wall. Client 2 fell to the floor. Client 2 was not injured. The GER further revealed that Client 1 was on close supervision (staff must be in the immediate area, hear the client at all times, and must make visual contact at least every 5 minutes) and was known to ?Wander about the unit.? There was no documented evidence in the GER that a staff person was in the immediate area when Client 1 pushed Client 2. A General Event Report (GER) was reviewed on 7/15/13. The GER indicated on 3/29/13 at 2:35 p.m., Client 1 was walking quickly in the hallway, suddenly became aggressive, and pushed Client 3 who was also walking in the hallway with a staff person. The staff person prevented Client 3 from falling. A General Event Report (GER) was reviewed on 7/16/13. The GER indicated on 4/14/13 at 10:15 a.m., Client 3 reached for Client 1?s shirt. Client 1 pushed Client 3 down to the floor and then pushed him twice as he was walking down the hall. Client 3 was not injured. The GER further revealed that Client 1 was on close supervision. There was no documented evidence in the GER that a staff person was in the immediate area when Client 1 assaulted Client 3. A General Event Report (GER) was reviewed on 7/16/13. The GER indicated on 5/20/13 at 3:30 p.m., Client 1 was pacing up and down the hallway, a precursor behavior. Client 4 was in the hallway at the same time.Client 1 pushed Client 4 up against the wall at the nurses? station and was holding him firmly until staff intervened. The GER further revealed that Client 1 was on general supervision (staff must make visual and/or verbal contact with each assigned client no less than every 15 minutes. This is the most common level of supervision). Client 4 was not injured. A General Event Report (GER) was reviewed on 7/17/13. The GER indicated on 6/20/13 at 9 a.m., Client 1 became agitated when Client 5 became upset. Client 1 bolted out of his room and pushed Client 5 forcefully with both hands throwing Client 5 against the wall in the hall. Client 5 hit the hand rail with his back and then fell to the floor resulting in a reddened area to his back. At 9:30 a.m., Client 1 was waiting to go to offsite with his peers including Client 3. Without warning, Client 1 pushed Client 3 into the wall resulting in a reddened area to Client 3?s elbow. A General Event Report (GER) was reviewed on 7/17/13. The GER indicated on 7/3/17 at 11:55 a.m., Client 1 had returned from an outing. Client 1 became agitated, a precursor behavior, and pushed Client 3 to the floor. Client 3 fell on his right knee. Client 3 became agitated and went toward Client 1 and was pushed down again by Client 1 resulting in Client 3 hitting his head against the wall. While staff was attempting to help Client 3, Client 1 attempted to hit Client 3. Staff prevented Client 3 from being injured. After this incident, Client 1 was placed on constant supervision (staff must be able to see and/or hear each client and be in close enough proximity to intervene as necessary). On 7/17/13, at 11 a.m., during interview Staff A stated that Client 1 could be an extremely dangerous client and that his aggressive behaviors posed a severe risk of injury to himself and to others. Staff A stated, ?We do the best that we can to keep him and the other clients safe. Sometimes, we cannot provide close supervision as we are working with another aggressive peer. We need to look at increasing his activity. When he paces, this is an indication that he needs to be more physically active. We attempt to keep him engaged in group activities, however most of the time he walks out. We are trying to find the right medication for him, having a problem with this also. He is a challenge to keep the other peers safe from him. Often there are no visible antecedents observed at the time he assaults. He probably would do better if he was on constant supervision, but he goes from general to constant depending upon what he has done. We should look at his supervision level closer.? The facility document titled, ?Supervision of Clients? policy #460, dated February 2011, reviewed on 7/17/13, revealed the following: Close Supervision: Staff must be in the immediate area, hear the client at all times and must make visual contact every 5 minutes. Constant Supervision: Staff must be able to see and/or hear each client and be in close enough proximity to intervene as necessary. General Supervision: Staff must make visual and/or verbal contact with each assigned client no less than every 15 minutes. This is the most common level of supervision. The facility document titled, ?Behavior Support Plan,? dated 7/16/13, reviewed on 7/17/13, revealed that Client 1?s chain of aggressive and assaultive behaviors were observed during a manic state and he would engage in assaulting peers as a means of disrupting the environment or seeking attention from staff. He might push or strike a peer, run quickly down the hall and then watch as staff intervened. Staff were to physically block Client 1 if he attempted to assault a peer. Staff were to clear the hallway of potential victims when Client 1 was running up and down. Staff were to remove an agitated peer away from Client 1 to prevent Client 1 from assaulting the peer. On 9/12/13, at 11 a.m., during interview Staff A stated, ?We will be moving the client to another unit. We have no idea why this client acts the way he does and constantly assaults other peers. There are many peers on this unit that he can target and they are unable to get out of harm?s way.? During review of Client 1?s medical record, under the section titled ?Psychologist Evaluations,? there were missing written evaluations by the psychologist addressing Client 1?s assaultive behaviors on the following dates: 3/28/13, 3/29/13, 4/14/13, 5/20/13, 6/20/13 and 7/3/13. On 9/12/13, at 1 p.m., during interview Staff B stated that after each peer to peer altercation, the unit psychologist was to do an evaluation and to chart it in the Psychologist Evaluation and Progress Notes. Staff B stated, ?This is important information for the staff to know in taking care of these assaultive clients.? On 9/12/13, at 1:30 p.m., during an interview Staff C stated, ?Well, most of the time we try; sometimes we miss getting the evaluations into the chart. I know that we are to do the evaluations when there is an altercation between clients.? The facility document titled ?Sonoma Developmental Center Policy Behavior Support & Intervention Services,? dated June 2006 and reviewed on 9/12/13, revealed that a psychologist or other person trained in behavior analysis was to complete a behavior analysis and include results in a written evaluation. The behavior assessment should have been sufficient to understand and treat the behavior problem. The facility failed to ensure that four clients were protected from immediate threat to their safety and prevented from harm by a client with identified assaultive behaviors when: 1) staff did not provide sufficient supervision for Client 1, and 2) staff failed to immediately intervene when Client 1 exhibited precursor behaviors which included running down the hallway, tapping walls excessively, screaming, agitation, restlessness and banging on walls prior to harming others which resulted in four peers being assaulted by Client 1. These violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150010151 |
B |
27-Feb-14 |
SI5G11 |
3516 |
W149 483.429(d)(1) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, or abuse of the client.The facility failed to ensure a client's right to be free from neglect. A client with PICA behavior (persistent ingestion of nonnutritive substances), requiring close supervision, was observed with a wad of fabric in his mouth. Staff providing supervision was observed using his cell phone in the presence of two clients. On 6/5/13, review of the IPP (Individual Program Plan), dated 1/31/13, indicated that Client 1 was blind and was diagnosed with profound intellectual disability, kyphoscoliosis (curvature of the spine), and external hip rotation. He moved about in a squat position using his hands to sweep the area for obstacles. Client 1 was nonverbal and communicated with distinctive vocalizations, body language and posture and occasional words.During a monitoring visit on 6/5/13 at 2:35 p.m., the surveyor entered the Family Two group room, room 130, and observed Staff A, seated at a table in front of Client 1. Staff A was observed looking down at his cell phone.When the surveyor entered the room, Staff A, who was not observing Client 1, immediately put the phone in his pocket. The surveyor asked, "What are you doing?" Staff A replied, "checking my e-mails." Concurrently, Client 1, who was seated in front of Staff A, was observed to have a wad of fabric material in his mouth. Staff A immediately reached over and removed the fabric.The surveyor asked Staff A if the cell phone that he was using was his own personal cell phone and he stated,"Yes." Staff A also stated that he should not be using his cell phone.The IPP indicated that Client 1 had a behavior plan for "Harm to Self-PICA." Additional documentation in the IPP indicated that Client 1 wore non rip shirts and denim jeans due to property destruction and PICA and he would tear clothing to obtain strings to place between his cheek and gums.Further IPP documentation indicated that Client 1 was visually impaired and required close supervision (staff must be in the immediate area and must make visual contact at least every five minutes) at the residence and day program to ensure his whereabouts and to prompt him to safely move away from obstacles he may bump into.The GER (General Event Report), dated 6/5/13, indicated that Client 1 had a preference to mouth items with cloth and strings being his preferred items and he liked having a ball of the material between his cheek and gum. The GER further indicated that Client 1 had access to his preferred item, a cotton cloth shirt, as staff had not dressed him in adaptive clothing. Additional GER information indicated that the item Client 1 chewed upon was one of Client 1's T-shirts, as the T-shirt had a label on it, when all of the pieces were found they matched exactly with no pieces missing. The GER documented that it was possible that unfamiliar staff did not know that Client 1 was not to have such garments.The facility policy for "Code of Conduct and Professional Behavior, #102, effective 12/2011, contained the following entry: "Use of personal equipment must not be on state time unless prior approval is given by the employee's Program Director or Department Head or during a major emergency. Examples of personal or state equipment include but are not limited to: Cell phones ..." The failure to protect Client 1 from neglect had a direct or immediate relationship to the health, safety, or security of patients. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150010293 |
B |
27-Feb-14 |
BDSK11 |
10434 |
Title 22 DIV5 CH 8 ART 4 - Clients' Rights 76525(a)(20) (a) Each client has the right listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to prevent neglect by failing to ensure implementation of facility policies for neglect prevention. Pills were found on the floors of multiple units, some housing clients with profound intellectual disabilities and some with pica behaviors (ingestion of non-edible items) placing those clients at risk.Some pills were identified as those belonging to clients who potentially did not receive medication as prescribed. Pills were found under furniture in client rooms and outside a unit front door on 4/18/13, 4/19/13, 4/23/13, 4/24/13, 4/26/13, 5/1/13, 5/4/13, 5/5/13, 5/6/13, 5/7/13, and 5/9/13, available to any client, staff, or visitor. This failure affected the clients on six of six certified Intermediate Care Facilities for the Intellectually Disabled (ICF/IID) units (Units: Stoneman, Poppe, Malone, Cohen, Roadruck, and Bentley). On 4/18/13, the facility submitted written reports to the Department that on 4/18/13, a housekeeper performing duties on Roadruck Unit found a pill, identified as 300 milligrams (mg) of Lithium (a mood stabilizer) mixed with some clothing in Client 1's room. The facility reported that Client 1 was not prescribed Lithium, but two other clients who reside on the unit currently had orders for Lithium.The facility also reported that on 4/18/13, another housekeeper on Roadruck Unit found four additional pills on the floor behind a couch near the nursing station. The pills were identified as two Metaglycemix tablets (nutritional supplements), one Lithium capsule and another unidentified tablet which appeared to be a vitamin.During an interview on 4/19/13 at 2:34 p.m., Supervising Housekeeper (SH) B stated Housekeeper A found the first pill in Client 1's room while performing routine cleaning duties. SH B stated that she went to the unit to cover for Housekeeper A while that housekeeper completed documentation for the pill found in Client 1's room. SH B stated that when pulling out the couch by the nursing station next to the medication room, she noticed four more pills and notified the shift lead.SH B stated housekeeping staff were expected to perform "detailed cleaning" of the units two times per week but no less than one time per week. She stated "detailed cleaning" included moving furniture to clean behind and under furniture, clean floors and walls and wipe the furniture down. SH B stated there was no log being used to track or monitor this procedure to ensure that staff completed the "detailed cleaning" as required however, housekeeping supervisors could tell if it was done when they came to do their daily checks.SH B stated she spoke with housekeeping staff following this incident and stated no one had reported additional ongoing problems with finding pills on the units. On 4/19/13, the facility submitted a written report to the Department that a housekeeper found a pill on 4/19/13, identified as DVPA (Depakote - an anti-seizure medication) on Roadruck Unit in Client 2's room. The pill appeared old but was intact. The facility reported Client 2 had current orders for that medication, but the two other clients in that room did not. The report documented that the room had been thoroughly cleaned by housekeeping and that housekeeping would continue to do a thorough cleaning of the unit.During record review on 4/19/13, the facility provided a list that identified 12 clients with pica behaviors (a behavior of ingesting non edible items) on Roadruck. During an interview on 4/22/13 at 2 p.m., Unit Supervisor (US) C stated the pill found in Client 1's bedroom on 4/18/13 and near the nursing station looked old and it could not be determined how long it had been there. US C stated the pill found in Client 2's room was found against a wall behind a dresser and said housekeeping conducted a thorough cleaning and no other pills were located. US C stated staff would continue to identify and assess clients for medication administration issues and swallowing problems. She stated at this time, all clients now received their medication in the medication room pending review at the next client protection plan (CPP) meeting.Unit observation, accompanied by US C, on 4/22/13 from 3 p.m. to 3:10 p.m. revealed multiple items on the floor that could potentially be hazardous to clients with Pica. The items included a nickel sized button under Client 1's bed; a small piece of paper/tape material under a couch in room 155, and a small black battery, approximately 1/2 inches long, in family room 3. During an interview at 3:10 p.m., US C stated clients in this group were high functioning and the items found were not preferred pica items for clients in that group.During a meeting on 4/24/13 at 3:30 p.m., Administrative Staff (Staff X) stated the facility took the issue of pills being found on the floor very seriously and was working very hard to correct the situation.During a follow up interview at approximately 4:30 p.m., Staff X stated that staff would be conducting medication pass observations that evening to ensure safe administration of medications.On 4/24/13 the facility submitted a written report to the Department that on 4/23/13 and 4/24/13, staff found additional pills on Bentley and Cohen units during facility wide environmental sweeps implemented in response to prior incidents of pills found. The reports documented the following:a.) On the evening of 4/23/13, an unidentifiable old white pink pill with thickened dry fluid stuck to it was found beneath a dresser in a client room.b.) On the afternoon of 4/24/13, housekeeping staff found an old capsule behind a dresser belonging to Client 3. The capsule was identified as ProEpa (a nutritional supplement). The facility reported Client 3's physician had changed the prescription two months ago from capsule form to liquid form due to Client 3's behavior of chewing on the capsule to drink the liquid and spitting out the capsule. The facility reported the capsule found under Client's dresser appeared old and dried and chewed.On 4/26/13 the facility submitted a written report to the Department and indicated that on 4/26/13 at 12:30 p.m. housekeeping staff found pills in two client rooms. The pills were identified as Vitamin B12, Thera-M (vitamin), Triazolam (a benzodiazepine), and another supplement, possibly Sinuplex. Two other pills could not be identified.During a medication pass observation and monitoring visit on Stoneman Unit, on 5/1/13 beginning at 7 a.m., the following was observed: At 7:50 a.m., a round white pill was observed in the corner of a client's room, room 149. At 8:20 a.m., a white pill, which was in two pieces, was in the corner of another client room, room 128. During an interview with Licensed Staff D on 5/1/13 at 2 p.m., Licensed Staff D stated she did environmental rounds between 6:45 a.m. - 7 a.m. and did not see the pills.Review of a facility report, received on 5/2/13, documented a pill found during the medication pass observation, on the floor in room 128 on the Stoneman Unit on 5/1/13. The report further revealed another pill identified as a Vitamin was also found on the floor of the unit. Concurrently on 5/1/13 a pill was found on a bathroom floor on the Poppe unit by a housekeeper. Continued cleaning of the Poppe unit revealed a second pill in the wheel of a hospital bed. Interview with Staff E on 5/7/13 at approximately 1 p.m., revealed that that the facility did not know at the time how this problem was still happening. Facility documentation further revealed that a thorough search of all the ICF/IID units at the facility resulted in the finding of 4 pills on the Cohen unit and 5 pills on the Malone unit. Review of a facility report, received 5/6/13, documented that on 5/4/13, 5/5/13, and 5/6/13, pills were found on the Bentley and Stoneman units. A Nifedipine pill (a calcium channel blocker used for chest pain [angina] and hypertension [high blood pressure]) was found on the Bentley unit; and, a Levothyroxine pill (a thyroid replacement or supplemental therapy) was found on the Stoneman unit. Review of a facility report, received 5/7/13, documented that on 5/7/13 a small brownish pill was found on the Poppe unit by a housekeeper. The pill was identified as Senosides (a laxative). Interview with Staff F on 5/7/13 at 2:35 p.m., revealed that there were two clients on the unit who took this medication, one in the evening and one in the morning. Staff F further stated that it was believed that the pill was from the client who took this pill in the morning. Review of a facility report received 5/9/13, documented that on 5/9/13 a pill was found on the ramp outside the front door of the Cohen unit. A second pill was found by the outside door. One of the pills was marked DSS (a stool softener) and the other pill was marked Keppra (an anti-seizure medication).Further review of the facility report showed that there was only one client on the unit that took Keppra and that client also was on DSS. Review of the facility Administrative Directive titled "Abuse/Mistreatment/Neglect Prevention and Reporting," dated July 2012, revealed the definition of neglect included: Failure to provide goods and services necessary to avoid physical harm ... lack of action that causes or may cause harm which may include but is not limited to failure to provide medical care, mental health needs ... protection from health and safety hazards ..."The above incidents indicated the failure to provide services and goods to avoid physical harm, the failure to provide medical care by failing to ensure clients received their medications as ordered, and the failure to provide protection from health and safety hazards by failing to ensure that objects and medications were not available for those clients with pica and when medications were accessible on the floors and under furniture for any client, staff, or visitor in the area. These failures had direct or immediate relationship to the health, safety, or security of patients. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150010294 |
B |
02-Apr-14 |
P2JN11 |
3550 |
T-22 CH 8 ART 4 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.The facility failed to ensure client safety and protection from potential serious harm when Client 1, with a history of elopement and limited safety awareness, eloped from the facility campus. The client traversed through rugged terrain and crossed a busy highway prior to being found by the county Sheriff.Client 1 was a 35 year old, with intellectual disability admitted to the facility on 9/16/08.Review of the facility incident report dated 6/27/13, indicated that on that date at approximately 10 a.m., as staff exited a van with Client 1 and others, at the day program site (Sunrise building), Client 1 ran to the opposite side of the building, out the door, and over a hill, out of sight as staff pursued him. The client was returned to the facility unharmed, by the county sheriff's department.Review of the client's record indicated that the day prior to this incident, on 6/26/13 at 2:30 p.m., Client 1 exited a van, jumped a fence into another yard, jumped a second fence and then was on the main campus and roads. Client 1 was kept in line of sight and returned home shortly thereafter though, per staff, Client 1 was highly agitated. The same day, Client 1 eloped twice from his residence, via an unlocked the back door. An Interdisciplinary Note (IDN), at 1 p.m. indicated that the client exited the back door (#149) twice. The client's record indicated a long history of elopement. According to a 2011 annual psychological evaluation: "Elopement carries the most significant risk as he has injured himself severely in the past and placed himself at risk this past year primarily due to lack of hazard awareness, and impulsive behavior." The client's behavior plan dated 3/12/12, described Client 1's behavior of elopement as "quickly bolts from supervised area..." The plan included: "Caution: client's limited safety awareness while eloping places him at serious risk of injury (e.g. cars) ..." and directed under the behavior of elopement, "if unsuccessful with verbal redirect physically block him and consider the use of physical escort, if necessary." A document dated 2/20/13 titled: Review of the Individual Program Plan (IPP) indicated that Client 1 lived on a locked residence and was "on constant supervision when off of the residence...constant supervision requires staff to be able to see and/or hear the client and to be in close enough proximity to intervene as necessary." During an interview on 9/10/13 at 2:15 p.m., the Licensed Staff (Staff A) who had been supervising Client 1 at the time of this incident stated the staff were very familiar with the client and that he had also attempted to elope the day before. Staff stated that the staff were especially alert to his behavior that day, because of elopements the day before.The facility failed to ensure the safety of a client with a known long history of elopement, and lack of hazard awareness, (particularly around cars), when he eloped a long distance and crossed a heavily trafficked highway before being found.This failure had a direct or immediate relationship to resident health, safety and security. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150010888 |
B |
31-Oct-14 |
38A511 |
3576 |
T22- DIV 5 CH 8 ART 3 - 76345 Health Support Services - Nursing Services (c) The attending physician shall be notified immediately of any signs of illness or marked change in condition.The Department determined the facility failed to ensure prompt medical care and treatment and assessment of the client (Client 43) by a physician for three days despite complaints of pain, edema, and bruising following an accident which resulted in a right foot fracture. Record review showed Client 43 was approximately 63 years old. Client 43 was ambulatory, diagnosed with abnormal movement disorders, impulse control disorder, attention deficit disorder of childhood with hyperactivity, and the client's medical history included a prior foot fracture and a history of contusions. An interdisciplinary note (IDN) signed by the Health Services Specialist (HSS), dated 4/5/14 at 10:30 a.m., indicated Client 43 fell and had scraped her left knee. The client sustained a superficial abrasion 2 centimeters (approximately 3/4 inch) on her left knee. No swelling or drainage were noted and ambulation was at baseline. HSS 1 stated during an interview, on 5/14/14 at 4:45 p.m., that she had looked at the patient on 4/5/14, Saturday, because the patient stepped in a pothole, fell to the ground and injured her knee. The HSS said she knew it happened in the morning, so the morning HSS also had looked at the injury. HSS 1 stated Client 43 had no pain or fever so the injury did not need further attention. The HSS also stated the incident was in the MD log book, and he (the physician) would check the log when he came in on Monday. HSS 1 stated Client 43 had osteoarthritis (a disease of the entire joint involving the cartilage, joint lining, ligaments, and underlying bone). The HSS indicated she was not aware if the client received pain medication but thought she received pain medication after the x-ray.An IDN, dated 4/5/14 at 8:15 p.m., revealed, the client had fallen on the a.m. shift and had complaints regarding her right foot. The noted showed, "Noted a large bruise w/ (with) edema (swelling) forming on top of R (right) foot below the ankle. Approx. (approximate) size 10 cm (centimeters) by 5 cm with red bruise, but perimeter is light purple. Wearing her shoes, but easily removes them..." Documented by the HSS on the IDN note, dated 4/6/14 at 8:55 p.m., was that the top of the right foot was red and swollen, and Client 43 was complaining of pain. There was no indication of notification to MOD (Medical Officer on Duty) / physician for further evaluation. The clinical record confirmed Client 43 did not have a physician evaluation until Tuesday, 4/8/14 at 9:40 a.m.. Documented in the "Physicians' Progress Notes," was, "Right foot w/ (with) mild swelling and diffuse bruising over foot. Patient refusing to allow palpation or further exam... bruising and injury is consistent with ankle sprain. Pt. (patient) is not limping or displaying signs of pain. In light of pt's (patient's) history of osteoporosis, will obtain x-ray today."The "Physicians' Progress Notes," dated 4/8/14 at 3:10 p.m., showed, "X-ray reveals fx (fracture) at base of 5th metatarsal (bone in the toe) - non-displaced. Fx (fracture) is c/w (consistent with) mechanism of injury Sat. (Saturday)..." The facility failed to ensure a medical assessment by the physician and provide prompt care for a patient with developmental disabilities after a witnessed fall, which resulted in a fracture, pain and swelling. These violations had a direct relationship to the health, safety or security of patients. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150010923 |
B |
19-Nov-14 |
EV8I11 |
4871 |
T22, DIV5 CH 8 ART 4 - 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. The facility failed to comply with the above regulation by failing to ensure Client 1 was adequately protected from harm when staff failed to identify the potential risk to Client 1 of being harmed by peers and failed to monitor peers with identified behavioral issues of biting other peers. These failures resulted in inflicted multiple bites to Client 1 with increasing seriousness of infection and tissue damage. A report received from the facility on 6/26/14, revealed on 6/26/14 at 7:05 a.m., staff discovered multiple human bites on Client 1. Bites were observed on Client 1's arms and lower leg. The bites had teeth impressions, opened skin areas, slight bleeding, swelling and bruising. A report received from the facility on 8/6/14, revealed on 8/2/14 at 7:20 a.m., staff observed a human bite mark on Client 1's upper arm. The facility report indicated that Client 1 was bitten - perpetrator unknown. Clinical record review starting on 7/17/14, indicated: Client 1 was a male, 35 years of age admitted to the facility on 4/2/1979. Client 1 had multiple diagnoses that included Profound Intellectual Disability, Autism and SIB (self-injurious behavior). Further review revealed that Client 1 had good receptive language skills and was able to make his needs known to staff verbally and through gestures. Client 1 received general supervision (staff must make visual and/or verbal contact with client no less than every 15 minutes) when on the unit and close supervision (staff must in the immediate area and must make visual contact every five minutes) at worksite. On 7/17/14, at 10 a.m., supervisory staff (Staff A) was interviewed. Staff A stated that a direct care staff had observed four bite wounds on Client 1's arms and leg during Client 1's shower. Staff A stated, "There were areas of broken skin, some dried blood, swelling and bruising. There were visible teeth marks on the skin. This client has a history of biting himself, however he will usually bite the back of his hand and he is a very large framed, overweight man with a large trunk girth and lacks the flexibility to be able to bite himself in the areas of his bite wounds. He is on general supervision during the day and night time hours and is checked every 15 minutes when awake and every 30 minutes when he is sleeping. This client enjoys his private time in his bedroom looking through his belongings and is usually in bed by 9 p.m. and asleep." Observation on 7/17/14 at 10:45 a.m., revealed that Client 1 had a private room. In addition to his bedroom door, his bedroom was accessible through a connecting restroom to an activity room. During a concurrent interview with Staff A, Staff A stated, "All the clients who use this activity room can also use the connecting restroom and they can go into this client's bedroom, too. This is why the staff is to monitor the clients using the activity room closely to prevent this from happening. Many of our clients like to use the activity room until very late in the evening. The staff will be training this client to use a press lock when he goes to bed to lock his side of the restroom for his security and staff must continue to monitor him for his safety from the other clients entering his bedroom." On 8/12/14 at 12 p.m., supervisory staff (Staff A) was interviewed. Staff A stated, "This is the second bite injury for this client. The direct care staff was starting his shower on 8/2/14 around 7:30 a.m., and noticed a red bite mark on his upper arm. Staff observed small skin openings in the bite area. We have eleven clients with behavior support plans in place for biting. This is a unit that can have biting issues. This client being bitten twice in a very short time is not the fault of the other clients on this unit. This is the fault of the staff on all three shifts. The staff failed to monitor and supervise our clients as they should have." The facility failed to comply with the above regulation by failing to ensure Client 1 was adequately protected from harm when staff failed to identify the potential risk to Client 1 of being harmed by peers and failed to monitor peers with identified behavioral issues of biting other peers. These failures resulted in inflicted multiple bites to Client 1 with increasing seriousness of infection and tissue damage. These failures had a direct or immediate relationship to the health, safety, or security of patients. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150010924 |
B |
31-Oct-14 |
JDOZ11 |
3610 |
T22 DIV5 CH8 ART4-76525(a)(20) CLIENT'S RIGHTSEach client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights:(20)To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to comply with the above regulation by failing to ensure that Client 1 was adequately protected from sexual abuse when her designated 1:1 (constant supervision) Staff A sexually abused her while on duty. A report received from the facility on 7/7/14, revealed on 7/4/14 at 11 p.m., Client 1 had informed on-duty staff that her individual supervision staff (1:1) from the A.M. shift had sex with her. The facility report indicated, "The client stated to staff that she had placed her soiled undergarments and sheets on top of her dresser and that she was scared to go back into her room and preferred to sleep outside in the hall that evening. She was transported to a local hospital at 3:30 a.m., on 7/5/14 for a SART (rape test) exam and further assessment. The alleged perpetrator was met on-site at 6:30 a.m., on 7/5/14. He was placed on administrative reassignment and detained by the Sonoma County Sheriffs' Office." Review of Client 1's record on 7/7/14, revealed that Client 1 had diagnoses of Post-Traumatic Stress Disorder (disorder characterized by recurrent episodes in which the patient relives a trauma - symptoms include nightmares, sleep disturbances, psychic numbness, flashbacks and aggressive behavior), chronic Mild Intellectual Disability and Borderline Personality Disorder (how the patient sees and acts in life - this is not an illness but rather how the patient relates to the world, can manifest in problems with low self-esteem, relating and trusting). Further review revealed that Client 1 had a history of sexual abuse by a family member as a child. During interview of a supervisory staff (Staff B) on 7/8/14, at 10 a.m., Staff B stated, "On 7/4/14, at approximately 11 p.m., the client reported to a night shift staff that a male staff had sexually abused her on the day shift. The client did not tell anyone about the incident until the night shift staff came on. The evening shift reported that the client had been scared and teary eyed most of the shift. The incident was immediately reported to the Sheriffs' Department by the facility's administrative staff. The client was taken to a hospital for further assessment and a SART exam was done. I do not have the exact test results, however I was informed that evidence was collected at the time of the exam. The accused staff member was removed from duty and arrested the next morning on 7/5/14." During interview with staff psychologist (Staff C) on 7/8/14 at 10:30 a.m., Staff C stated, "This client struggles with her compulsion to deal with emotional distress through extreme acts of self-injurious behaviors such as cutting herself and swallowing dangerous objects. She is stable at this time however maybe in six months she could become emotionally unstable as a result of this sexual assault. We need to monitor her closely." The facility failed to comply with the above regulation by failing to ensure that Client 1 was adequately protected from sexual abuse when her designated 1:1 (constant supervision) staff sexually abused her while on duty. These failures had a direct or immediate relationship to the health, safety, or security of patients. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150010982 |
B |
30-Oct-14 |
CZ4O11 |
3769 |
T22 DIV5 CH8 ART3 76315(b) Developmental Program Services-Individual Program Plan (b) The individual program plan shall be implemented as written.The facility failed to ensure implementation of the program plan when Client 1 ingested two keys subsequently found in her gastrointestinal tract. This had the potential to cause harm to Client 1 and was the second incident of ingestion of a foreign body in five weeks.The record, reviewed on 5/1/14, indicated that Client 1 had a behavior support plan for parasuicidal/self-injurious behavior/pica (ingestion of non-eatable items). A prior ingestion incident had occurred on 3/21/14 when the client ingested part of a safety scissor which had to be surgically removed. Review of the facility reported incident, dated 4/29/14, indicated that Client 1 reported ingesting two keys. The client was transferred to an outside community hospital for tests an x-ray confirmed the presence of two keys one in her esophagus and one in her stomach. Review of the record of Client 1 on 5/1/14 contained a behavior plan which included the need for individual supervision and direct line of sight at all times, last updated 4/21/14, the purpose of which was to avoid ingestion behavior. "Staff must provide Individualized Supervision (i.e. direct line of sight, within arm's reach) at all times, including worksite, sleep and hygiene (female staff should assist during bathing/toileting) with no exceptions." Review of a client protection plan and Individual Program Plan (IPP) special meeting, dated 4/30/14, indicated that on 4/28/14 at 4:30 p.m., Client 1's individual supervision was replaced by a male staff (Staff A). During this time the client wanted to take a shower. Staff A allowed the client to shower in private behind a closed curtain. During an interview on 5/1/14 at 1 p.m., Staff A stated at the time there was no female staff available and the client just got her things and went into the shower room, and could not be redirected. A special meeting document, dated 4/30/14, indicated that on 4/29/14 Client 1 had been agitated commencing that morning when the nurse noted a superficial opening of the 3/21/14 wound and recommended the use of an abdominal binder. The client left the off-site upset about this and was subsequently followed by hospital police and returned home. The client continued to refuse the binder and was placed in a pica safe room and became combative. At 4:25 p.m., Client 1 reported that she wanted to hurt herself. The client's supervision level was increased to two staff. During this time, the client reached down pulled a key from her sock and placed it in her mouth while staff attempted to redirect. The client then reported that she had swallowed another key the night before. The client's keys had been accounted for in her fanny pack by the evening shift staff. Review of the record on 9/9/14 included the IPP special meeting document dated 5/6/14, that indicated that the client returned from the hospital on 5/3/14 and the client had passed one key but not the other. A physician's progress note, dated 5/5/14, indicated that the surgeon managing the ingestion felt it was appropriate to resume a regular diet and wait to pass the second key at home. The plan was to monitor bowel movements closely until the passing of the second key. Review of the record on 9/9/14 indicated in the Interdisciplinary Notes, dated 6/1/14 at 1:50 p.m., that two keys were found in the client's stool measuring 4.5 centimeters in length and no trauma and no complaints as noted per the nursing assessment. In summary Client 1 swallowed two keys and her individual supervision/behavior plan was not followed. This failure had a direct or immediate relationship to resident health, safety and security. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150011100 |
B |
25-Feb-15 |
6U4V11 |
3961 |
T22 DIV5 CH 8 ART 3 - 76315 (b) Developmental Program Services-Individual Program Plan 76315(b) -The individual program plan shall be implemented as written. The facility failed to ensure that Client 1's mobility care plan was implemented. Client 1, at risk for injuries related to falls, was not provided the care and services that were outlined and identified in her mobility care plan. This failure to provide necessary care and services resulted in a fall and emergency hospital transport. The client sustained a fractured nasal septum, a deep lip laceration, and facial ecchymosis (bruising). On 10/1/14, review of Client 1's, "Medical History and Review of Systems," dated 2/4/14, indicated that Client 1 had profound intellectual disability. The IPP (Individual Program Plan), dated 2/5/14, indicated Client 1 was at risk of injuries related to falls, due to lack of safety awareness, hazard awareness, ataxia (lack of muscle control during voluntary movements) and an unsteady gait. Client 1 wore a non-removable helmet while ambulating and when seated without close supervision. Physician's orders, documented on 8/20/14, indicated that Client 1 was to wear well-fitting supportive tennis shoes for all weight bearing activities. A fall risk assessment score, dated 9/3 (no year entered) was 11. A score of 10 or above represented a high risk for falls. Client 1's mobility care plan, dated 3/19/14, indicated Client 1 performed all weight bearing transfers ranging from independently to a one person stand by assist. One person assist was to be used if Client 1 was unsteady. Additionally, Client 1 was to use a commode chair, without a seatbelt, during toileting. Review of the GER (General Event Report), dated 8/27/14, indicated at approximately 11 a.m. on 8/27/14, Staff A was assisting Client 1 to the restroom. Staff reported that Client 1 appeared to be drowsy, outside of baseline, as she had received Diphenhydramine 25 milligrams (Benadryl/a sedating antihistamine) at 9:30 p.m. on 8/26/14 for a health issue. Documentation indicated that Staff A assisted Client 1 to turn toward the toilet. The staff subsequently stepped away to gather supplies from the bathroom cabinet while maintaining eye contact with Client 1. Staff A witnessed Client 1's right foot catch behind her left foot as she attempted to walk towards the toilet unassisted, causing her to trip and fall. A code (medical emergency) was called and Client 1 was transferred to the acute care hospital. On 8/29/14 Client 1's right knee was noted with swelling and a faint bruise. On 8/30/14 Client 1 had increased knee swelling and developed a 7.5 x 3 cm (unit of measure) bruise. An x-ray was obtained. There was no fracture noted but fluid was present on her knee. Additional GER documentation indicated that Staff A was not prepared with the supplies before beginning to assist Client 1 and did not use Client 1's assigned stall that housed her commode chair. Additional GER documentation indicated, "Root cause appears related to staff using wrong restroom stall and moving too far away from [Client 1] as they noted she was more drowsy than usual." Staff A was not available for interview. During an interview with supervisory staff, Staff B, on 12/15/14 at 3:45 p.m., Staff B stated Client 1 was to be seated on a commode chair without a seatbelt. Staff B stated, "He left her standing in the stall without the commode chair." Staff B stated, he turned to unlock the cabinet to clean her up while he kept a visual on Client 1 and Client 1 fell. Staff B stated, "She apparently tried to step forward and probably got her feet caught."Therefore, the facility's failure to implement a mobility care plan for a client at risk for injury related to falls and for a client who was observed to be more drowsy than usual put Client 1 at an increased risk for falls and injuries. These failures had a direct or immediate relationship to the health, safety, or security of patients. |
| 630015624 |
Sonoma Developmental Center |
150011369 |
B |
16-Jul-15 |
N7OJ11 |
3402 |
T22, DIV5 CH 8, ART 4 - 76525 (a)(20)Client 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. Review of facility documentation on 2/12/15, revealed that Client 1 was reported to be missing from the Corcoran Unit at 9:30 p.m. on 9/29/13. She was found on facility grounds by the Eldridge Fire Department at 10:30 p.m.Review of Client 1's record on 2/12/15, revealed that she was 33 years old with diagnoses which include mild intellectual disabilities, and borderline personality disorder. Client 1 had a key to her bedroom that was given to her by Staff A. This key also opened the main entrance to the unit. Interview with the Staff A on 3/26/15 revealed that she had given the key to Client 1 but she did not realize that it also opened the main entrance.Review of facility documentation on 10/25/13, revealed that a community member called the facility to report a client on their property and the switchboard said no client had been reported missing and suggested they call 911. Review of the facility policy and procedure titled "Search for Missing Persons", effective date March 2010, on 4/29/15 revealed that there is no contingency in the procedures to follow should someone call from the outside the facility. Interview with Staff B on 4/29/15, verified that there is no contingency in place to follow should someone call in from the outside to report a possible missing client. Further review of Client 1's record revealed that she was on "General Supervision." Review of facility policy and procedure titled, "Supervision of Clients," effective January 2012, on 4/29/15, stated, "General Supervision: Staff must make visual and/or verbal contact with each assigned client no less than every 15 minutes. ..." Facility documentation showed that Client 1's group leader, Staff C, did not check on the client between 8:30 p.m. and 9:30 p.m. and that she did not ask for help from other staff to assume responsibility for the client while she was at lunch. Review of the facility policy and procedure further showed under "Assessment of Supervision Needs," "For all levels of supervision ..., staff will not reduce their assigned client's level of supervision until another employee has assumed the same level of responsibility for the client. Staff must know the whereabouts of the client, what they are doing, and the strategies used when interacting with the client." Review of documented interview with Client 1, dated September 30, 2013, on 05/07/15 revealed that Client 1 stated she left the unit at 2015 (8:15 p.m.). Client 1 further stated that she knew the time because she looked at her watch, and she did not tell anyone that she was leaving the unit. Based on the time that Client 1 said she left the unit, 8:15 p.m., until she was noted to be missing at 9:30 p.m. and was not found until 10:30 p.m. for a total time of 2 hours and 15 minutes that Client 1 was left unsupervised. The facility's failure to comply with the above regulation has a direct or immediate relationship to patient health, safety, or security. |
| 630015624 |
Sonoma Developmental Center |
150011633 |
B |
21-Oct-15 |
HZON11 |
3894 |
T22 DIV5 CH8 ART4-76525(a)(20) Client Rights (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to provide a safe environment, free of health and/or safety hazards when Client 1, a client with history of severe self-injurious behaviors and self-abusive behaviors, ingested a total of three (3) AAA batteries within a three day time period. Client 1's medical record was reviewed on 7/8/15. Review of Client 1's "Medical History and Review of Systems," dated 10/31/14, indicated that Client 1 had mild intellectual disability, borderline personality (disorder characterized by instability in moods, interpersonal relationships, self-image and behaviors), PTSD (Post Traumatic Stress Disorder), impulse control disorder, and SIB (self-injurious behaviors).Review of Client 1's "Semi Annual Review," dated 6/18/15, indicated Client 1 had the following behaviors: 1. Self-injurious behavior-cutting herself or ingesting dangerous non- food items. 2. Self-abusive behavior-drinking mouthwash, refusing to eat, inducing emesis (vomiting), or drinking excessive amounts of highly caffeinated energy drinks. Review of the facility's General Event Report, dated 7/5/15, indicated that on 7/5/15 at 8 p.m., while Client 1 was in her bedroom with staff providing 1:1 individual supervision, Client 1 reported that she did not feel well, was dizzy, and felt like she was walking on air. At that time, Staff A was giving Client 1's Individual Support Person a break. Client 1 began to cry and stated that she did something. Staff reassured Client 1 and encouraged her to tell staff what she had done. When Staff B entered the room, Client 1 sat up in her bed and began crying hysterically. Documentation indicated that she bolted up, went to her TV stand, picked up a green box, shuffled through it, grabbed a AAA battery, and "shoved" the battery in her mouth. Staff pleaded with her to spit it out but she dropped herself to the floor, covered her mouth, and swallowed the battery. Documentation further indicated that Client 1 had informed staff that she had also swallowed one battery on "Thursday" (7/2/15) and another battery on "Friday" (7/3/15) during her "private time." Documentation indicated Client 1 had seven incidents of pica (ingesting non- food items) since 3/2014. A medical emergency was called and Client 1 was transferred to the Emergency Department where it was confirmed, via x-ray, that she had a battery in her stomach and two more in her colon. Staff A stated during an interview on 7/20/15 at 1:50 p.m., that Client 1 reported that she, "did something." Staff A stated that Staff B, the Individual Support Person for the second half of the shift entered the room and both staff were seated on the side of Client 1's bed with Client 1 in the middle. Client 1 was crying and rushed out of bed. Staff A asked, "what are you doing?" Staff A stated that Client 1 went to the television stand and "popped" a battery in her mouth so fast. She threw herself to the floor, put her face in a grocery bag and became combative, dragging Staff A.Staff B stated during an interview on 7/20/15 at 2:30 p.m., that she was providing individual supervision for Client 1 for the second half of the shift from 7 p.m. to 11 p.m. Staff B stated that Client 1 was upset and told her that she did something bad in a "joking" manner and out of nowhere she went to the television stand, picked up a long box, dropped to the floor, and swallowed the battery. Staff B further stated that the police counted 28 batteries on the floor. Therefore, the facility failed to prevent neglect by failing to ensure a safe environment for a client with self-injurious behaviors that were manifested by swallowing non-food items. This failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 630015624 |
Sonoma Developmental Center |
150011638 |
A |
29-Jul-15 |
VZHM11 |
14759 |
T22-DIV5 CH8 ART4-76525(a) (20)-Client Rights (a) Each client has the right listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights:(20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect.The facility failed to prevent neglect by failing to ensure that adequate supervision was maintained for provision of a safe environment free of health and /or safety hazards.1) Client 1, with severe self-injurious and self-abusive behaviors, and with a prior history of ingesting mouthwash on 8/20/12, purchased and consumed a bottle of mouthwash, while being supervised/mentored, during an off campus shopping trip.2) Client 1 ingested a metal clasp used to hold papers in filing folders (verified by x-ray). 3) Client 1 stated that she obtained nail polish remover pads from a peer. The client consumed three pads. 4) Client 1 ingested two metal strips from face masks (verified by x-ray). The facility policy for "Abuse/ Neglect Prevention & Reporting," #413, effective 2/14, contained the following definition of neglect: "Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Any willful act or lack of action that causes or may cause harm which may include but is not limited to failure to provide...protection from health and safety hazards..." 1. On 11/10/14, the Department received notification from the facility of an entity reported incident for Client 1 regarding ingestion of mouthwash on 11/9/14. On 1/14/15, review of the "Medical History and Review of Systems," dated 10/31/14, indicated that Client 1 had mild intellectual disability, borderline personality (disorder characterized by instability in moods, interpersonal relationships, self-image and behaviors), PTSD (Post Traumatic Stress Disorder), impulse control disorder, and SIB (self-injurious behaviors).Further documentation indicated that Client 1's self injurious behaviors were manifested by swallowing nonfood items which have included scissors and keys. Review of the IPP (Individual Program Plan), dated 12/17/13, indicated Client 1 had the following objectives: B1-1: Para-suicidal- threats; Threats /statements of wanting to "harm self" by engaging in SIB (self injurious behaviors) with no intent to cause death. B1-2: Para-suicidal - SIB /pica (craving or ingestion of nonfood items) -Cutting or scratching self with sharp objects, cheeks then stores medications for overdose, excessive alcohol ingestion (e.g., mouthwash), tearing open surgical incision site, self-inflicted laceration of genital or anal area, or other types of self injury including swallowing dangerous objects such as nail clippers, alcohol-based products (mouthwash), batteries, bottle caps, saran wrap, hand sanitizer, strips of vinyl from furniture or metal or plastic pieces. B1-3: Elopement - Leaving staff supervision without prior approval. Past incidents have occurred during walks on grounds, trail hikes, and bike rides. Additional documentation indicated that Client 1 no longer had a denial of rights for her personal possessions or for body searches. (The client no longer had restrictions to her personal possessions that could cause her potential harm).On 1/14/15, review of the General Event Report, (GER), dated, 11/9/14, indicated on 11/9/14 Client 1 attended an off campus shopping trip, accompanied by staff, and purchased nine (9) items. Documentation indicated that all of the purchases were in a cart but the items were piled on top of each other and the mouthwash was never seen.Upon return to the residence, staff checked on Client 1 every 15 minutes. At 8 p.m., documentation indicated that Client 1 "was fine" and playing video games. At 8:15 p.m., Client 1 was found lying on her side on her bedroom floor. A "code" (medical emergency) was called. Documentation indicated that Client 1 was breathing and her coloring was pink but she did not respond when her name was called. When the emergency responders arrived she began to flail her arms and legs and rolled herself from side to side but did not respond. On 3/1/15, review of "Physicians' Progress Notes," dated 11/9/14 at 9 p.m., indicated that upon the physician's arrival, Client 1 began flailing on the floor with intermittent pauses. After approximately 20 minutes of this activity, she was transferred to an empty room for her safety at which time she asked for Trazodone (antidepressant/antianxiety medication) and Tequila. Her pulse was 131(normal adult pulse range is between 60-100 beats per minute), respirations were 20, and her blood pressure was unobtainable. Her oxygen saturation was 98% on room air. Documentation indicated that she was awake, ataxic (loss of muscle coordination, especially the extremities) with slightly slurred speech. Further documentation indicated that housekeeping staff found an empty 500ml (milliliter/unit of measure) bottle of antiseptic mouth wash in the client's trash can containing 21% ETOH (alcohol) with menthol and eucalyptus extracts. The "A/P" (assessment/plan) documented, "Acute ETOH (alcohol) intoxication from illicit ETOH consumption."Further GER documentation indicated that during the assessment period, Client 1's breath smelled "very much like mouthwash." Documentation indicated that Client 1 had given the Social Workers a receipt for the items she purchased and a bottle of mouthwash was the second item listed. Documentation indicated that Client 1 later stated, "I put the mouthwash in my cabinet and locked it." Client 1 told staff that she drank the mouthwash. During an interview with Staff A on 1/14/15 at 11:30 a.m., Staff A stated, on the day of the incident, she was Client 1's mentor and had accompanied her to the Dollar Store. She stated there were at least four staff present with approximately six clients on the outing and they left the unit before 3:30 p.m. When asked about Client 1's supervision level, Staff A stated, "When you know where she is at all times; not within arm's reach." Staff A stated, while at the store, she followed Client 1 and when she purchased her items she was right next to her. Staff A stated she saw the items but did not see the mouthwash. Staff A stated that she, herself, purchased an item so she could be close to Client 1 in line to be sure she was appropriate and to monitor the interaction with the cashier.During an interview with the Unit Supervisor, Staff B, on 2/24/15 at 10 a.m., Staff B confirmed that every client was on constant supervision (staff must be able to see and /or hear each client and be in close enough proximity to intervene as necessary) when in the community. The Level 3 GER report indicated that staff was with Client 1 and she was under visual monitoring, however, the staff's proximity and angle were behind her and not close enough to see what Client 1 had on the check-out belt. 2. On 2/2/15, the Department received notification from the facility of an entity reported incident for Client 1 regarding ingestion of a metal clasp (flat metal strip used in filing folders to hold papers with two holes on top) on 1/31/15. On 2/11/15, review of the GER, dated 2/2/15, indicated on 2/2/15, at around 10:15 a.m., Client 1 complained of right upper quadrant abdominal pain and the physician was notified. While the physician conducted the examination, Client 1 told the physician she swallowed a piece of metal used in filing folders two days prior (1/31/15). The physician ordered an X-ray of the abdomen and at 1:45 p.m., results indicated a metallic foreign body. Client's supervision was increased from 1:1 (one to one) to 2:1 (two to one) and Client 1 was moved to the pica safe room (room cleared of objects that could be swallowed) under full pica protocol and a special team meeting was held at 2:30 p.m. On 3/1/15, review of the "Individual Supervision and Mentoring Guidelines for [Client 1]," dated 10/22/14, indicated Client 1 was on general supervision (staff must make visual and /or verbal contact with each assigned client no less than every 15 minutes) during the day shift on the unit and at Sunrise (day program). On the evening shift, she was on general supervision, but a "mentor" was available to her, as needed. The job of the mentor was to check on Client 1 every two hours, talk with her, offer to provide companionship or invite her to do an activity. The mentor would not stay if Client 1 preferred to be alone. On the night shift, Client 1 was provided with individual supervision (staff must be able to see their assigned client at all times and be in close enough proximity to protect them and others from injury) with female staff only. During an interview with Staff D on 3/10/15 at 11:30 a.m., the staff stated on 2/2/15, at 10:10 a.m., Client 1 was on 1:1 supervision and complained of abdominal pain. When she assessed the client, Client 1 complained of right upper quadrant abdominal pain. She notified the physician and when the physician was examining Client 1, the client told the physician she swallowed a metal clasp from the filing folder. The physician ordered the X-ray of abdomen and the report confirmed metal foreign object. On 3/10/15, Client 1's clinical record was reviewed and the Interdisciplinary Notes, dated 2/4/15, with a 10:00 p.m. time entry, indicated in part, "At approx. 2130 (9:30 p.m.) [Client 1] said she needed to go to the bathroom, when her ISP (Individual Supervision Plan staff) checked her stool, the metal clip that she swallowed was there." 3. On 2/10/15, the Department received notification from the facility of an entity reported incident for Client 1 regarding ingestion of four nail polish remover pads on 2/9/15. On 2/24/15, review of the GER, with report date of 2/9/15, indicated on 2/10/15 at approximately 9:45 a.m., during Client 1's check in, (five minute talks with the psychologist, residence manager, IPC, and sometimes the group leader, where the client was given the opportunity to discuss anything she wanted to). Client 1 stated that she had ingested four nail polish remover pads (3cm x 3cm) on 2/9/15 during the p.m. shift. She reported she obtained them from a peer in the beginning of January, hid them in her phone case and unwrapped them under her covers while in bed. Documentation indicated that she stated the reason she ingested them was because she had a craving for alcohol the night of 2/9/15 due to her ongoing anxiety. She stated she "stuffed" the wrappings between her bed and the wall that the bed was pushed up against. Documentation indicated that Client 1 ingested three pads instead of four pads, as the wrappings were retrieved and one package still contained a "square" (nail polish remover pad). On 3/2/15, review of the "Individual Supervision Guidelines for [Client 1]," dated 2/5/15, indicated, due to an incident where Client 1 ingested a metal clip, she was now on one to one individual supervision on all shifts. During an interview with Staff C on 2/24/15 at 10:45 a.m., Staff C confirmed that Client 1 was on ISP (individual supervision). Staff C stated that Client 1's peer got the nail polish remover pads from the beautician. Staff C stated that she and Staff B performed a pica sweep and found three (3) empty nail polish remover packages and the pica protocol was initiated. (The pica protocol gives guidance for staff on preventative measures, assessment indicators and monitoring requirements related to pica). Further documentation in the GER that indicated that Client 1 and her peer were on ISP at the time one client gave Client 1 the pads. Client 1 stated that she and her peer were sitting across from each other in the dining room with the ISPs on each side. A wall was on the other side of the clients. Documentation indicated Client 1's peer "slipped" the nail polish remover pads to her with a handshake across the table and she put them into her pocket and put them inside her phone while under the covers. Further documentation indicated that Client 1 stated she knew her BSP (Behavior Support Plan) no longer "made her keep her hands above the covers." 4. On 2/23/15, the Department received notification from the facility of an entity reported incident for Client 1 regarding ingestion of two metal strips from face masks on 2/23/15. On 2/24/15, review of the GER and Interdisciplinary Notes, dated 2/23/15, indicated on 2/23/15 at around 1:10 p.m., Staff F approached Staff G and said Client 1 told her she ingested metal strips from two face masks and was complaining of upper abdominal pain. The physician was notified who ordered an X-ray of abdomen which identified two metal objects. On 3/1/15, just as during the 1/31/14 incident, review of the "Individual Supervision and Mentoring Guidelines for [Client 1]," dated 10/22/14, indicated Client 1 was on general supervision during the day shift on the unit and at Sunrise (day program). On the evening shift, she remained on general supervision with a "mentor" available as needed. The mentor, again, was to check on Client 1 every two hours, talk with her, offer to provide companionship or invite her to do an activity and the mentor would not stay if Client 1 wanted to be alone. On the night shift, Client 1 had individual supervision with female staff only. During an interview with Staff F on 3/10/15 at 3:10 p.m., she stated on 2/23/15, Client 1 told her she had swallowed two metal strips from face masks. Client 1 asked the ISP 1:1 staff for the masks because she had been coughing and the ISP staff gave her the masks. Client 1 told Staff F she did it in her bedroom after dinner. During an interview with Staff C on 3/10/15 at 3:45 p.m., face masks used on the unit were inspected and the staff showed the thin metal strip inside the top of the mask which measured approximately 5.5 inches in length. On 3/16/15, Staff E provided the "Operative Report," dated 2/24/15, which indicated, "Procedure Performed: Upper endoscopy with foreign body removal from the stomach" and both metal strips were removed from Client 1's stomach. Therefore, the facility failed to prevent neglect by failing to ensure provision of adequate supervision to assure a safe environment that was free of health and safety hazards as it related to a repeat incidence of mouthwash ingestion, ingestion of two different types of metal pieces, and ingestion of nail polish remover pads within a 4 1/2 month period of time.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. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150011694 |
B |
29-Oct-15 |
CDCH11 |
12423 |
T22-DIV5 CH8 ART4-76525(a) (20)-Client Rights (a) Each client has the right listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights:(20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect.The facility failed to prevent neglect by failing to ensure that adequate supervision was maintained for provision of a safe environment for a client with poor hazard awareness, at high risk for falls, and with a history of multiple incidents of elopements while residing on an unlocked residence.1) On 2/23/15 at 9:15 a.m., residence staff received a call that Client 1 was outside in the middle of the street and was almost hit by a car. The client was last seen on the residence at 8:50 a.m. Client 1 had eloped 5 times in February 2015 prior to this incident. 2) On 2/26/15 at approximately 5:55 p.m., Client 1 was found outside in the parking lot of a neighboring residence in the driver's seat of a van.The policy for "Abuse/ Mistreatment/Neglect Prevention & Reporting," #413, effective 2/15, included the following definition of neglect: The negligent failure of any person to care for a resident or to exercise that degree of care that a reasonable person in a like position would exercise.Review of the IPP (Individual Program Plan), dated 11/18/14, indicated Client 1 was at high risk for potential falls, injury/fracture related to ataxia (failure of muscular coordination), poor hazard awareness, previous history of fracture, and seizure activity. Client 1 required a non-removable hockey style helmet with 1/2 face shield to be worn.The client's level of supervision was general on the unit, close at the day program and constant on grounds and in the community. Per facility Administrative Directive Section 400 titled: "Supervision of Clients" 460 effective August 2014, indicated the following definitions: General Supervision: Staff must make visual and/or verbal contact with each assigned client no less than every 15 minutes. Close Supervision: Staff must be in the immediate area and must make visual contact at least every 5 minutes. Constant Supervision: Staff must be able to see and/or hear each client and be in close enough proximity to intervene as necessary.Review of the record on 3/25/15 contained an Interdisciplinary Note (IDN) dated 2/4/15 at 8:45 a.m. The IDN indicated that Client 1 was seen by staff exiting the unit at approximately 8:30 a.m. Staff observed client walking towards the van and was brought back without any incidents. The plan was to continue to follow plans and increase supervision level. On 2/4/15 a Client Protection (CPP) meeting was documented regarding the incident on 2/4/15. There was no plan indicated. A Behavior Support Plan for elopement, initiated on 2/5/15, described this behavior as, "leaves the unit from the front door". There was no indication of increase in level of supervision. The functional analysis indicated the client's preference for vehicles, (van, electric carts, tram) bikes and swings. There are bikes and swings in the backyard.An IDN dated 2/5/15 at 9:30 a.m., indicated that Client 1 was very active and walked out the front door with staff following and redirected him back inside. An IDN dated 2/6/15 indicated that that 8 a.m. staff saw Client 1 bolt out of the front door and run across the lawn towards the parking lot and a moving van. Staff intervened redirecting inside.An IDN dated 2/10/15 indicated that at 8:50 a.m., Client 1 walked out of the front door, and ran across the grass to the van in the parking lot and attempted to enter the van. Staff attempted to redirect as did psychologist, who then stayed with the client at the van.An IDN dated 2/11/15 at 9:50 a.m. indicated that Client 1 was standing at the front door with peers. When the door opened, the client bolted past staff to the sidewalk. Staff was able to remain with client who then walked in the crosswalk to the middle of the street and dropped to the ground. Staff was able to redirect back to the sidewalk and they walked to the off-site. A CPP dated 2/11/15 indicated the plan to get the client a swing for the backyard and the courtyard is open at 7:45 a.m. The client had not eloped from there. The team considered transfer to a locked unit and the psychologist will price durable swings.On 2/11/15 a "Special Meeting" was held that addressed the recent 5 elopements out of the front door thus far in February. This document added the information that on 2/11/15 the client was attempting to get to the tram across the street. Also, that it took two staff to redirect the client after he dropped to the ground in the middle of the street to redirect him to the sidewalk. The team also reviewed his supervision level and increased it on the unit from "general" to "close" to monitor for elopements. Another "Special Meeting" dated 2/12/15 added interventions of making the glass on the front door less easy to see through, and planned for increased outings. A meeting was also planned with the regional center and client's parent's, regarding the client moving to a locked unit. The document indicated that the Client was at risk for injury on an unlocked unit due to lack of hazard awareness. On 2/13/15 another "Special Meeting" indicated that the interdisciplinary team met with the client's parents regarding moving to a locked residence. Parents also believe Client 1 is in need of being on a locked residence at this time. An IDN dated 2/23/15, indicated that staff on Client 1's unit, received a call from the facility operator at 9:15 a.m., that Client 1 was outside. Unit staff then saw that a staff was with the Client at this time in the crosswalk of the street. The client then bolted away from staff and headed toward the back of a moving car that had just passed them. There were numerous attempts, to redirect the client back to the unit. The client frequently dropped to the ground and would not move. A second attempt to run into the street was blocked by two staff. The client's level of supervision on the unit at this time was close. Review of the facility General Event Report (GER) indicated that on the morning of 2/23/15 Client 1 was in the back courtyard. His group leader (Staff B) brought the client inside to the group area. Staff B then began another assignment without communicating that fact to any other staff. It was determined that 8:50 a.m., was the last time the client was seen on the unit by staff. The unit was notified the client was outside at 9:15 a.m. The client's level of supervision at this time was "close" when on the unit. (Close Supervision: Staff must be in the immediate area and must make visual contact at least every 5 minutes). During an interview, on 5/18/15 at 12:40 p.m., Staff A stated that Staff B left his group assignment (of which Client 1 was part) early to take over an individual supervision of another client. In addition, thus far the facility has not been able to find placement for Client 1 on a locked unit. On 7/14/15 during a subsequent interview Staff A added regarding the 2/23/15 incident: "He (Client 1) came so close to being hit by a car that day." During an interview, on 6/10/15 at 9:30 a.m., Staff B stated that he remembered hearing that Client 1 got out, however at that time he (Staff B) was already with another client. Staff B stated that he would not have left his group without reporting off to another staff member. Staff B was unable to recall to whom he reported.On 3/6/15, review of the "Behavior Support Plan," dated 2/23/15, indicated Client 1 had the following behavior: B4- "Elopement" - Leaves the unit from the front door. The plan was initiated on 2/5/15 and revised on 2/23/15 following an elopement incident. Documentation indicated that Client 1 liked van rides and would stand for 15-20 minutes staring out the windows in the doors at the van, golf cart, or other familiar vehicle. Review of the document, "Special Meeting: Review of Elopements," dated 2/11/15, indicated that Client 1 eloped out of the front door of the unit on 2/4/15, 2/5/15, 2/6/15, 2/10/15 and 2/11/15. The team reviewed Client 1's level of supervision, which had been general on the residence. Further documentation indicated, Client 1's level of supervision "will now be close" on the residence to help monitor for elopements while allowing the freedom to be outside in the courtyard. A subsequent "Special Meeting," dated 2/24/15, indicated since 2/4/15, Client 1 eloped seven times. On 3/6/15, review of the GER (General Event Report), dated 2/27/15, indicated on 2/26/15 at approximately 5:55 p.m., Client 1 was found outside in a van in the parking lot of a neighboring unit in the driver's seat with the seatbelt on. Per the psychologist's report, Client 1 was missing for less than five minutes.Further GER documentation indicated since the last elopement event, Client 1 was under close supervision with a staff hand off (means of providing consistent communication between staff). Close supervision was defined as; Staff must be in the immediate area and must make visual contact at least every 5 minutes. Documentation indicated that staff failed to implement new plans of protection from 2/23/15 to hand off Client 1 and ensure his five minute checks. GER documentation indicated that Staff C, assigned to the 1A group area, gave Client 1 a shower at approximately 5:20 p.m. and after the shower was completed at approximately 5:35 p.m., Staff C could not get Client 1 to go to his Group 1 area so he left him alone in the Group 2 area. Further documentation indicated that Staff C moved on to check on the rest of the group, as they were preparing for dinner. Staff C said he did not check on Client 1 from that point on until he went looking for him at dinner. At 5:55 p.m., when group 1 went into the dining room for dinner, it was noted that Client 1 was not with them. On 3/6/15, review of "Physician's Progress Notes," dated 2/26/15, indicated that Client 1 has had several elopements from the unit this month. Since changing his seizure medications his level of activity and strength of gait is improved. Being on an unlocked unit is not working out. During an interview with Staff C on 3/11/15 at 2:55 p.m., Staff C stated on 2/26/15 he arrived on the unit between 4:35 p.m. - 4:40 p.m. and was assigned to Family 1A with another staff member. He stated there were 8 clients and 2 other staff providing 1:1 supervision in the group. The AM staff endorsed that Client 1 was in the backyard. Staff C stated he first checked on [Client 1] at 4:45 p.m. while he was sitting on the swing and then he went to check on other clients at 4:50 p.m. Staff C stated at approximately 5 p.m., everyone was relaxing and he was helping the float staff and doing activities with the clients in Family 1. At 5:15 p.m., Staff C stated that he needed to double check on [Client 1] at which time he was happy on the swing. At that time, Staff C stated that [Client 1] needed personal care and he gave him a shower between 5:35 p.m. - 5:40 p.m. Staff C stated after the shower, he wanted to bring Client 1 to Group 1 but Client 1 did not want to go. Client 1 was in the hallway by Family 2. Staff C stated, "I left him there" and went back to Family 1. Staff C stated at 5:50 p.m. it was time for dinner and he had to be sure that everyone was there. Client 1 was not in the hallway or in the back yard. He checked the front door, dining room, and unit's van and he was not there. At 5:55 p.m. he was found sitting in a van at a neighboring unit. When asked about his supervision level, Staff C stated Client 1 was on close supervision and he was told by the Unit Supervisor to check [Client 1] every 5 minutes.Staff A stated, "at 5:45 p.m. it did not get done. It got done at 5:50 p.m." Staff C stated, "I wasn't able to check because I had to watch the whole group." Therefore, the facility failed to prevent neglect by not ensuring provision of adequate supervision to ensure a safe environment in a client with poor hazard awareness, at high risk for falls, and with a history of multiple recent elopement incidents. This failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 630015624 |
Sonoma Developmental Center |
150011986 |
B |
30-Jun-16 |
Q51S11 |
3021 |
Health and Safety Code-1418.91(a). (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. The facility failed to ensure that an incident of neglect (behavioral ingestion of non-food items) was reported to the CDPH (California Department of Public Health) immediately or within 24 hours. This failure created a delay in CDPH oversight and the investigative process. Client 1's record was reviewed on 1/7/16. The "Medical History and Review of Systems," dated 12/30/15, indicated that Client 1 had mild intellectual disability, impulse control disorder, and SIB (self-injurious behaviors). Documentation indicated, Client 1's SIB was manifested by swallowing non-food items that included repeated incidents of paperclip ingestions, with one incident requiring surgical intervention; ingestion of batteries; metal from two isolation masks; ingestion of nail polish remover pads; a metal bracket from her chart; keys; and scissors, which required surgical intervention. On 1/7/16, during investigation of ingestion of a non-food item on 1/1/16, an additional behavioral ingestion incident was noted in the IDNs (Interdisciplinary Notes). The incident occurred 15 days prior, on 12/23/15, as follows: Client 1's IDNs, dated 12/23/15 at 8 p.m., indicated at approximately 7:45 p.m., staff went into Client 1's room, per her request. Client 1 stated, "I need to show you something." Client 1 got up and reached under her recliner and handed staff two paperclips. Client 1 was asked if she swallowed a paper clip and she stated, "Yes, I did swallow the big one." An ACNS (Assistant Coordinator of Nursing Services) IDN dated 12/23/15 at 8:20 p.m., indicated Client 1 said she swallowed a paper clip, the big one, she opened it, swallowed it, and it got stuck in her throat. Documentation indicated that her voice sounded hoarse. Client 1 was transferred to the Emergency Room. On 1/7/16 at 2 p.m., Standards Compliance Staff, Staff A, was asked if the 12/23/15 incident had been reported to CDPH. On 1/7/16 at 2:05 p.m., Staff A stated the incident was reported and provided a letter addressed to the Department, dated 12/24/15. The letter indicated Client 1 reported that she had swallowed a straightened large paper clip that she had taken from her vocational training program. A hand written entry on the top of the letter indicated, "12/24/15 12:47 CDPH." Upon further investigation, review of a facility email document entitled, "[Name of facility] Self Report of Incident," indicated the report was not sent to CDPH. During an interview with Staff A, on 1/7/16 at 2:17 p.m. Staff A stated the notification was sent to [Name of facility] internally but not to CDPH and the letter did not get forwarded to CDPH. Therefore, the facility failed to ensure a reportable incident was reported to CDPH. This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150012012 |
B |
09-Mar-16 |
4DLH11 |
2239 |
HSC 1418.91 (a) (b) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation.The facility failed to comply with the above regulation and report an allegation of neglect within 24 hours. This failure resulted in a delay of California Department of Public Health (CDPH) oversight and investigation into the event, client contact by the alleged neglector continued, which potentially placed other clients at risk of neglect. An 8/18/15 review of the facility's General Events Report (a summary of the facility's investigative findings) found that Client 1 fell while walking with her sister on 7/18/15. The fall was unwitnessed by staff. Health Services Specialist 1 (HSS 1) was called to assess and provide nursing interventions. RN 1 alleged that HSS 1 did not personally assess the client, and that HSS 1 stated that RN 1 should make it easier by not mentioning that Client 1 hit her head. During a telephone interview with RN 1 on 8/18/15 at 3:30 p.m., RN 1 reviewed the duties of an HSS, which included assessing clients in the facility following certain events, including falls. RN 1 indicated that HSS 1 did not assess Client 1 following the fall on 7/18/15. RN 1 stated she had asked HSS 1 if the "Head Injury Protocol," dated December 2013, should be initiated. RN 1 stated HSS 1 replied, "Do not tell anyone she hit her head. It will make more work for the staff." A review of the letter reporting this allegation of neglect to the CDPH by the facility was dated 7/23/15. The report showed that RN 1 reported this allegation of neglect to the facility four days after the event, delaying notification to the CDPH. A review of facility Administrative Directive 346, effective June 2015, showed allegations of neglect were to be reported within 2 hours. Therefore the facility failed to report an allegation of abuse according to the time parameters in HSC 1418.91 (a) when RN 1 waited four days to report the allegation.The facility's failure had a direct relationship to the health, safety and security of patients. |
| 630015624 |
Sonoma Developmental Center |
150012333 |
B |
14-Jul-16 |
87FL11 |
5349 |
T 22 DIV 5 CH 8 ART 4 Administration 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. The facility failed to comply with the above regulation when Client 1 was left behind in a building restroom for one hour alone with no supervision, and assigned staff was unaware of her absence until a custodial staff cleaning the building found the client in the restroom. The facility reported incident indicated that on 4/18/16 at 3 p.m., custodial Staff A reported to the supervising psychiatric technician, Staff B, a client was still in the classroom (Farrell E). "Upon entering the classroom she (Staff B) heard knocking from the restroom." She went to the stall and found the client on the toilet and escorted her back to the Smith unit. The Individual Program Plan (IPP) dated 6/17/15 for Client 1 indicated she was non-verbal and communicated by using facial expression, gesture and behavior. The client was at risk for choking related to pica behavior (ingestion of non-food items) and falls and injury related to lack of hazard awareness. The client's level of supervision was general on the unit and constant at the offsite. Levels of supervision were defined in Administrative Directive 460 dated February 2016 1.2.1 "General Supervision: Staff must make visual and/or verbal contact with each assigned resident no less than every 15 minutes." Section 1.2.3 "Constant Supervision: Staff must be able to see and/or hear each resident and be in close enough proximity to intervene as necessary." On 5/2/16 at 10 a.m., Licensed Staff C stated that one person on Smith residence was assigned by the Senior Psychiatric Technician each shift to document clients leaving and returning to the residence. At the offsite, Farrell E, documentation was done by either Staff D or F. Nursing Protocol P 903 titled, "Change of Shift, Communication and Routine Accountability Checks Protocol," Section I 1. "All staff participates (sic) in exchanging information regarding clients, and their whereabouts. The assigned staff will make complete living residence rounds. All clients must be accounted for by completing a face-to-face acknowledgment and will be per their level of supervision." The "shift lead will...document (at) change of shift on the 24 hour log, including...client accountability..." "Minimally the following information should be considered for each client at each change of shift report; this information must be documented on the 24 hour log form as well as verbally communicated to the oncoming shift......'client accountability tracking'......2. Differences in client count and the number assigned to the residence must be reconciled and documented on (the) 24 hour log..." Review of the 24 hour log for Smith Residence dated 4/18/16 documented an entry at 1430 (2:30 p.m.) "Change (inserted for symbol) of shift report, group assignments, dinner breaks." Between the last entry 2:30 p.m. on the 24 hour log and 3 p.m., when the client was discovered at the offsite there was no indication of client whereabouts. On 5/2/16 at 1:30 p.m., Licensed Staff D stated that at the off-site for Farrell E, Licensed Staff F was in charge and accountability was done by Smith Staff (Staff C and E). During an interview on 5/4/16 at 1 p.m., non-licensed Staff E stated on 4/18/16 at about 1:20 p.m., Staff F assisted Client 1 to the restroom. Staff E then escorted clients back to Smith residence beginning at about 1:30 p.m. On 5/4/16 at 1:30 p.m., during an interview, Staff F stated she did not know who took Client 1 to the restroom the day of the incident. Regarding the client accountability log at the off-site (Farrell E) Licensed Staff F stated Smith staff, (Staff C and E) did the client accountability log that day. Staff F stated on 4/18/16 after returning to the off-site from escorting clients to Smith, Staff F left the off-site early and Staff H, from an adjacent room, stated he would be there until 3 p.m. Review of the document titled: "Client Supervision/Accountability Tracking" (addendum to the 24 hour log) indicated that on 4/18/18 Licensed Staff C signed Client 1 out of Smith Residence at 9:05 a.m., and back in at 15:10 (3:10 p.m.) (when she was returned having been found in the offsite bathroom. The time entry was written over what appeared to be 13:50 (1:50 p.m.). The document titled: "Off residence......Daily Huddle/Accountability Log" for 4/18/16 indicated that Client 1 was assigned to Staff E, at the off- site had a check off mark that indicated Client 1 returned to Smith residence with her peers. In summary, the facility failed to ensure constant supervision for Client 1 per her plan at the off-site and general supervision at the residence, when Client 1 was unaccounted for between 1:30 p.m. and 3 p.m. without staff knowledge and was inadvertently found by a custodial staff, alone in the off-site building rest room stall. This failure had a direct or immediate relationship to resident health, safety and security. |
| 630015624 |
Sonoma Developmental Center |
150012490 |
B |
11-Aug-16 |
L5F311 |
5047 |
Title-22 DIV 5, CH 8, ART 4 - Administration: 76525(a) (20) Clients' Rights 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: To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to prevent neglect by failing to ensure provision of a safe environment, free of health and/or safety hazards, when Client 1, with a history of ingesting metal from a face mask in 2/15, accessed and ingested a metal piece from an isolation face mask while being provided 2:1 (2 staff for 1 client) supervision. This failure resulted in ingestion of a non-edible item (metal) and transfer to the hospital for removal of foreign objects. Client 1's medical record was reviewed on 1/7/16. The "Medical History and Review of Systems," dated 12/30/15, indicated Client 1 had mild intellectual disability, borderline personality (disorder characterized by instability in moods, interpersonal relationships, self-image and behaviors), PTSD (Post Traumatic Stress Disorder), impulse control and SIB (self-injurious behaviors). Further documentation indicated that Client 1's self-injurious behaviors were manifested by swallowing non-food items which included scissors (without the handle), requiring surgical intervention, in 3/14; keys in 4/14; a metal bracket from a chart in 1/15; four nail polish removal pads in 2/15; metal pieces from isolation masks in 2/15; three AAA batteries in 7/15; and open paperclips in 10/15 and 12/15. The GER (General Event Report) dated 1/1/16, indicated on 1/1/16 at 7 p.m., Client 1 reported that she had swallowed a piece of thin metal from a face mask she found in her bathroom trash can. Documentation indicated she pretended to throw something away in the trash can and wadded up the mask in her hand to hide it and placed it in her bra to ingest it later. GER documentation indicated that the facility was on restriction for norovirus and Client 1 knew if "she" went on restriction, staff would wear masks. GER documentation indicated the unit had previous training in 2/15, from another event, which instructed staff not to discard masks in Client 1's room. The shift lead was asked to remind each staff that no masks should be left in her room or thrown in the garbage and not to allow Client 1 to wear a mask. Staff passed this information onto the night and a.m. shifts on 1/1/16. The "Individual Supervision Guidelines," dated 12/31/15, indicated that Client 1 was currently being provided two to one individual supervision (one male and one female staff) on all shifts. Female ISPs (Individual Supervision Persons) were to directly observe Client 1 during bathing, toileting and dressing/changing clothes. The male ISP was to wait just outside the bathroom or shower room and just outside her bedroom while she was dressing. Further documentation indicated, due to Client 1's recent ingestion of another paper clip, ISPs must be in a position that allowed them to see her face and mouth. This was the level of supervision at the time of the incident. Review of the "Operative Report," dictated on 1/2/16, indicated Client 1 underwent an esophagogastroduodenoscopy (a procedure to visualize the gastric area, via a scope) with foreign body removal on 1/1/16. Two foreign objects were seen and removed, one in the esophagus (muscular tube connecting the throat with the stomach) and the other in the stomach. A long linear plastic and metal foreign object was present in the distal esophagus and there was a curved foreign object present in the fundus (upper curvature of the stomach) with a density on x-ray indicating it was metal. On 11/27/15 at 11:30 a.m., Staff A stated she worked with Client 1 previously, was familiar with her behavior plans, and was aware that Client 1 had ingested metal in the past. Staff A stated, "The plans change so much." Staff A stated she worked the night shift on New Year's Eve, was held over on New Year's day, and supervised Client 1 for five hours from 10 a.m. to 3 p.m. Staff A stated Client 1 was a 2:1 (two staff to 1 client supervision). Staff A stated, when relief staff came to replace her, she took her gown and mask off, rolled the mask in the gown, and "tossed" it in the trash can. Staff A stated she was "overly exhausted" and the metal on the mask did not occur to her. Therefore, the facility failed to prevent neglect by failing to keep Client 1's environment free of face masks with metal which the client might ingest. The facility failed to provide a safe environment for a client with a history of a previous ingestion of metal from a mask and a known extensive history of repetitive self-injurious behaviors manifested by swallowing non-food items. These failures had a direct or immediate relationship to the health, safety, or security of patients. |
| 630015624 |
Sonoma Developmental Center |
150012491 |
B |
12-Aug-16 |
6DWC11 |
7190 |
TT 22-DIV 5, CH 8, ART 4- Administration Client's Rights-76525(a)(20) (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to prevent neglect by failing to ensure provision of a safe environment free of health and/or safety hazards for Client 1, who had severe self-injurious and self-abusive behaviors. Client 1, while being provided 2:1 (2 staff to 1 client) supervision and with a history of multiple behavioral ingestions of paperclips, accessed and ingested a paperclip she obtained at the day program. This failure resulted in ingestion of a partially opened paperclip necessitating hospitalization for removal of the paperclip. Client 1's medical record was reviewed on 1/7/16. The "Medical History and Review of Systems," dated 10/31/14, indicated that Client 1 had mild intellectual disability, borderline personality (disorder characterized by instability in moods, interpersonal relationships, self-image and behaviors), PTSD (Post Traumatic Stress Disorder), impulse control and SIB (self-injurious behaviors). Further documentation indicated that Client 1's self-injurious behaviors were manifested by swallowing nonfood items. Interdisciplinary Notes (IDNs), dated 12/23/15 at 8 p.m., indicated, at approximately 7:45 p.m. Client 1 told Staff A, "I need to show you something." Client 1 reached under her recliner and handed Staff A two paperclips. Staff A asked Client 1 if she swallowed a paper clip and Client 1 said, "Yes I did swallow the big one." Review of Client 1's "Individual Supervision Guidelines," dated 12/16/15, indicated Client 1 was "currently on two to one Individual supervision "New 12/16: (either one male and one female or two female staff) on all shifts. Beginning Sunday, 12/20 on NOC (night) shift , [Client 1] may have one ISP (individual supervision person) rather than two during NOC shift as long as her behavior continues to be safe." Documentation indicated, due to Client 1's recent ingestion of another paperclip, ISPs were to be in a position that allowed them to see Client 1's face and mouth (to allow staff to monitor for ingestion of items). At the work setting, Individual Supervision Guidelines indicated during work periods, Client 1 was to work in the pica (persistent ingestion of non-nutritive items) safe room doing either shredding of "cleaned" paper (no staples or paper clips) or folding towels and napkins. The ISPs were to remove all staples and paperclips from the paper in the large shredding bin and place only "cleaned paper" in Client 1's small shredding bin. The GER (General Event Report), dated 12/23/15, was reviewed on 1/7/16. Documentation indicated on 12/23/15 at 7:45 p.m., Client 1 reported that she swallowed the large paperclip, upon returning home from work. She stated she opened it, swallowed it, and it got stuck in her throat. Documentation indicated her voice sounded hoarse. GER documentation indicated Client 1 had full access to Sunrise building 7 (worksite) and she could have accessed the paperclips anywhere. GER documentation indicated that although the client was assigned to work in the pica safe room, Client 1 had access to the whole building that was not pica free. GER documentation indicated Client 1 stated she "smuggled" three paperclips out of Sunrise (work site) by hiding them in her bra. Client 1 stated she was in her room when she snuck the paperclip in her mouth but was only able to get the paperclip partially open because staff were watching her. Client 1 was transported to the acute care hospital and an x-ray confirmed the paperclip was still in her throat. The acute care "ED (Emergency Department) Complex History Physical," signed on 12/24/15, contained the following entry: Plain film imaging of the chest, abdomen, and pelvis showed a large partially unfolded paperclip extending from the esophageal hypopharynx (part of the throat) down approximately one quarter of the esophagus (tube that connects the throat to the stomach). The distal end (farthest end) was closed. Additional documentation indicated at 10 p.m., Client 1 was placed into observation status overnight. At "0025" Client 1 was found to be gagging and coughing and part of the paperclip was extruding from her mouth. The paperclip was manually removed in the emergency department and Client 1 returned to the unit on 12/24/15 at 2:30 p.m. Multiple staff members, who provided individual supervision on 12/23/15, were interviewed, as follows: Staff B, interviewed on 4/26/16 at 9:10 a.m., stated she worked with Client 1 for 30-45 minutes at the worksite and did not notice anything. Staff B provided supervision to Client 1 from 6:30 a.m. to 10:30 a.m. on 12/23/15. Staff B stated she checked papers for paperclips and staples before giving them to Client 1 to shred. Staff B stated, "She is good at trying to distract." Staff C, interviewed on 2/3/16 at 2:45 p.m., provided supervision to Client 1 at the worksite from 10:30 a.m. to 2:30 p.m. with Staff D. Staff C stated that she did not notice anything. Staff C stated she removed staples from the papers and handed Client 1 papers one by one. Staff C stated, "There were no paper clips." Staff D, interviewed on 6/28/16 at 9:11 a.m., provided supervision from 10:30 a.m. to 3 p.m. with Staff C. Staff D stated, "We were right there helping her do her work." He stated he remembered that Client 1 did not want him to sit too close to her. Staff D stated he did not see any paperclips. Staff E, interviewed on 2/3/16 at 3:10 p.m., provided supervision on the unit from 3 p.m. to 7 p.m. on 12/23/15, with Staff C, who worked a double shift. Staff E stated Client 1 was in her recliner watching television while both ISPs were on either side of her. Staff E stated that he did not see anything. Staff F, interviewed on 2/3/16 at 3:07 p.m., provided supervision on the unit from 6:30 p.m. to 10:30 p.m. with Staff G. Staff F stated, "She did not swallow in front of me." Staff F stated that she stayed "only" in her room and watched television. Staff G , interviewed on 4/26/16 at 9 a.m., provided supervision with Staff F from 7 p.m. to 10:30 p.m. Staff G stated Client 1 was fine and was her usual self. GER documentation indicated this was the seventh behavioral ingestion this year. Client 1 had three events in 2/2015 involving 2 metal items along with nail polish remover pads, on 7/5/15 she ingested a battery, and 10/14/15 and 11/4/15 she ingested a paperclip. Therefore, the facility failed to prevent neglect by failing to ensure a safe environment for Client 1, who was allowed full access to the Sunrise building (worksite) that was not pica free and who had a known extensive history of self-injurious behaviors that were manifested by swallowing non-food items. This failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 630015624 |
Sonoma Developmental Center |
150012492 |
B |
11-Aug-16 |
69EJ11 |
4419 |
T 22 DIV 5 CH 8 ART 4 Administration 76525 (a) (20)-Clients' Rights 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: To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to prevent neglect by failing to ensure provision of a safe environment when individual supervision levels were not maintained, as outlined in Client 1's "Individual Supervision Guidelines" document. Client 1's ISP (Individual Supervision Person) was observed with her head down and eyes closed. This failure resulted in an unsafe environment and had the potential for Client 1 to engage in a behavioral ingestion when she was not being observed or supervised by her ISP. The "Medical History and Review of Systems," dated 12/30/15, indicated that Client 1 had mild intellectual disability, borderline personality (disorder characterized by instability in moods, interpersonal relationships, self-image and behaviors), PTSD (Post Traumatic Stress Disorder), impulse control and SIB (self-injurious behaviors). Further documentation indicated that Client 1's self-injurious behaviors were manifested by swallowing non-food items which have included scissors (without the handle), requiring surgical intervention, in 3/14; keys in 4/14; a metal bracket from her chart in 1/15; four nail polish removal pads in 2/15; metal strips from isolation masks in 2/15; three AAA batteries in 7/15; and paperclips in 10/15 and 12/15. Client 1's "Individual Supervision Guidelines," dated 1/8/16, indicated Client 1 was currently being provided one to one individual supervision with female staff only on all shifts. Further documentation indicated, due to Client 1's recent ingestion of another paperclip, ISPs must be in a position that allowed them to see Client 1's face and mouth. On 1/19/16, the General Event Report (GER), dated 1/11/16, was reviewed. Documentation indicated a DRC (Disability Rights Coordinator) representative visited Client 1 on 1/8/16 at 9:30 a.m. and observed Client 1's ISP (Staff A) with her head down, "as if she were nodding off." Documentation indicated that Staff A was held over from the night shift, was assessed for duty, and the assignment with Client 1 was deemed appropriate. GER documentation indicated, "Being [Client 1's] ISP involves watching her hands and face at all times which could not take place if the staff's head was down." Further documentation indicated that the incident occurred on Friday, 1/8/16, and was not reported to the facility until Monday, 1/11/16, when the Department of Quality Assurance was notified by the Volunteer Advocacy Coordinator. Staff B was interviewed on 1/19/16 at 1 p.m. Due to the late reporting, three days after the incident, Staff B stated that Staff A worked on Friday, 1/8/16, and also worked the following Monday, 1/11/16 until 2:30 p.m., before being reassigned. The DRC was interviewed on 1/14/16 at 4:10 p.m. The DRC stated on 1/8/16 between 9:30 a.m. - 10 a.m., she was meeting with Client 1 in the kitchen area with Client 1's 1:1 present. The DRC stated she witnessed Client 1's 1:1 with her eyes closed and her head to the side and the staff appeared to be "nodding off." The DRC stated Client 1 called Staff A's name two to three times before she opened her eyes. ISP staff, Staff A, was interviewed on 1/27/16 at 10:15 a.m. Staff A stated that she worked on the night shift on 1/7/16 and volunteered to work overtime, on the day shift, on 1/8/16. Staff A stated that her aunt was ill and stated, "At one point I did close my eyes for a little bit." Staff A stated, "I did look down" and said that she was sending "goodwill" to her aunt. When asked if she fell asleep, Staff A stated when she opened her eyes she did not remember feeling like she had just woken up. Staff A stated, "I'm not going to say no, I don't really know if I nodded off." Therefore, the facility failed to ensure a client's right to be free from neglect when provision of a safe environment was not maintained and "Individual Supervision Guidelines" were not implemented. This failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 630015624 |
Sonoma Developmental Center |
150012493 |
B |
12-Aug-16 |
MDN111 |
4711 |
T22-DIV5 CH8 ART4-76525(a) (20)-Client Rights (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to prevent neglect by failing to ensure provision of a safe environment free of health and/or safety hazards when Client 1, under individual supervision, accessed and later ingested a paperclip that she stated she obtained from the office supply/arts and crafts room. This failure resulted in Client 1 ingesting a paperclip which necessitated a transfer to the hospital for retrieval of the paperclip via endoscopy (procedure used to visualize the digestive system with a tiny camera on the end of a long flexible tube). The "Medical History and Review of Systems," dated 12/30/15, indicated that Client 1 had mild intellectual disability, borderline personality (disorder characterized by instability in moods, interpersonal relationships, self-image and behaviors), PTSD (Post Traumatic Stress Disorder), impulse control and SIB (self-injurious behaviors). Further documentation indicated that Client 1's self-injurious behaviors were manifested by swallowing nonfood items which have included scissors (without the handle), requiring surgical intervention, in 3/14; keys in 4/14; a metal bracket from her chart in 1/15; four nail polish remover pads in 2/15; metal from isolation masks in 2/15; three AAA batteries in 7/15; and an open paperclip in 10/15 and 12/15. Review of the "Individual Supervision Guidelines," dated 1/20/16, indicated Client 1 was currently receiving one to one individual supervision with female staff on all shifts. Documentation indicated due to Client 1's recent ingestion of a mask wire, ISPs must be in a position that allowed them to see Client 1's face and mouth to prevent ingestion of potentially harmful items. The General Event Report (GER), dated 1/25/16, indicated Client 1 stated Staff A took her to the office supply /arts and crafts room, room 145, on the a.m. shift on 1/23/16. Client 1 stated, "Staff was not looking when I grabbed a paper clip and hid it in my right sock. I pretend (sic) that I was scratching my lower leg." Further documentation indicated that Client 1 stated, later that night, she swallowed a big paper clip after taking her 8 p.m. medication while lying down in her bed. Client 1 also stated that Staff B was reading a newspaper next to the door. Client 1 stated, "I straightened it out and swallowed it while I'm [sic] laying in bed and then it got stuck so I cough [sic] it up and pulled it out and bent the tip of the clip to go down easier and drink [sic] my water." GER documentation indicated this was Client 1's ninth (9th) behavioral ingestion this year. Additional documentation indicated that Client 1 was determined and sneaky and, as of late, was not showing antecedents for this behavior. Staff A was interviewed on 5/12/16 at 1:25 p.m. Staff A stated that she did not take Client 1 into the Arts and Crafts room and further stated, "We couldn't do that because of her access." Staff A stated, "She may have more than one story." Staff B was interviewed on 6/28/16 at 10 a.m. Staff B stated she provided supervision for Client 1 from 7 p.m. to 11 p.m. on 1/23/16. Staff B stated she was working overtime hours and had not worked on the unit for three years. On 1/23/16 at 2:30 p.m., Staff B was informed that she was going to be assigned to supervise Client 1. Staff B stated she did not receive any orientation regarding care for Client 1 and was provided a binder (information about the client). Staff B stated she, "read everything on her," read her binder, and followed her plan. Staff B stated she followed Client 1 to dinner at 5:30 p.m. and Client 1 became upset and mad and told Staff B, "Don't read my binder." Staff B denied reading a newspaper while providing supervision to Client 1 and stated the "room was black," the door was locked, and the heater was "So strong" Staff B stated she was fanning herself with a magazine. Therefore, the facility failed to prevent neglect by failing to ensure a safe environment for Client 1 who had an extensive history of self- injurious behaviors that were manifested by swallowing non-food items. At some point, Client 1 accessed and swallowed a paperclip while being provided individual supervision. This failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 630015624 |
Sonoma Developmental Center |
150012501 |
A |
16-Aug-16 |
TS3U11 |
6902 |
T22-DIV5 CH8 ART4-76525(a) (20)-Client Rights (a) Each client has the right listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to provide a safe environment, free of health and/or safety hazards when Client 1, with a history of severe self- injurious and self-abusive behaviors ingested a paperclip on 10/13/15. This failure necessitated a transfer to the acute care hospital and subsequent surgery for removal of the paperclip. On 10/16/15, Client 1 underwent an extensive laparoscopic lysis of adhesions (cutting tough bands of scar tissue via insertion of a thin telescope-like instrument through an incision in the abdomen) and laparoscopic small bowel resection (surgery to remove part of the small bowel) for foreign body retrieval. Client 1 returned to the unit on 10/20/15. Client 1's medical record was reviewed on 10/20/15. Client 1's "Medical History and Review of Systems," dated 10/31/14, indicated that Client 1 had mild intellectual disability, borderline personality (disorder characterized by instability in moods, interpersonal relationships, self-image and behaviors), PTSD (Post Traumatic Stress Disorder), impulse control disorder, and SIB (self-injurious behaviors). Documentation indicated Client 1's SIB was manifested by swallowing non-food items. Review of Client 1's "Semi Annual Review," dated 6/18/15, indicated Client 1 had the following behaviors: 1. Self-injurious behavior-cutting herself or ingesting dangerous non-food items. 2. Self-abusive behavior- drinking mouthwash, refusing to eat, inducing emesis (vomiting), or drinking excessive amounts of highly caffeinated energy drinks. Review of the "Individual Supervision Guidelines," dated 10/6/15, indicated Client 1 was provided individual supervision with female staff only for all shifts. It was recommended that the ISPs (individual supervision persons) maintain a distance of three to four feet between themselves and Client 1 to help ensure Client 1's anxiety and related behaviors did not escalate due to her feeling claustrophobic or feeling trapped. Additional documentation indicated ISPs could stay closer than three to four feet whenever it was necessary for safety. Under the heading, "Access," documentation indicated Client 1 was no longer restricted from using small parts and PICA ( ingestion of inedible objects) sweeps (scanning the environment for potentially dangerous items that could be consumed) would no longer be done except in urgent situations where Client 1 was acting unsafe. Under "Work Setting," documentation indicated Client 1 was cleared to work in any area of the worksite and she could handle small parts such as rivets (mechanical fasteners) with her ISP supervising all of her work. Review of the GER (General Event Report), dated 10/16/15, indicated on 10/14/15 at 4:15 p.m., Client 1 reported that she was not feeling well and was in pain. She informed her therapist that she had swallowed a paperclip on 10/13/15 at 5 p.m. because she wanted to harm herself. Client 1 indicated it was a large size paperclip which she straightened out prior to ingesting it so, "it would hurt more." Client 1 reported she took the paperclip while at her worksite and that she had been, "very sneaky" when she swallowed the paperclip when the staff member was not looking. Client 1 reported nausea and pain in her right lower quadrant of her abdomen and was transported to the emergency department. Client 1 was subsequently admitted to the hospital following confirmation of one paperclip in her small bowel and underwent a surgical procedure for removal of the paperclip. GER documentation indicated Client 1 had seven similar events in the last 24 months. The incidents were as follows: 3/27/14 - scissors, 4/29/14 - a key, 6/1/14 - a key, 11/9/14 - a bottle of mouthwash, 2/2/15 - a metal clasp, 2/11/15 - nail polish remover pads, 2/22/15 - two wires from a protective mask, and 7/5/15- ingestion of batteries. Review of the Special Meeting, dated 10/15/15, indicated staff asked Client 1 why she swallowed the paperclip. Client 1 stated, "I wanted attention." Staff D was interviewed on 10/20/15 at 9:30 a.m. Staff D stated she provided individual supervision to Client 1 from 3 p.m. to 7:30 p.m. on 10/13/15. Staff D stated she was positioned close to Client 1 while Client 1 was using her lap top, playing games, and sharing pictures of her family. Staff D stated that Client 1 "looked sad" and she asked what was wrong. Client 1 said she did not feel well and complained of stomach pain, but did not say anything about ingestion. During an interview with offsite staff, Staff A, on 10/21/15 at 1:30 p.m., Staff A stated that some of the papers that Client 1 shredded were paper clipped together and some were stapled. Staff A stated the next day when he went into the room at the worksite where Client 1 shredded, there was a jar full of paperclips on her table. Staff A stated, "she was allowed to do this." Staff B was interviewed on 10/27/15 at 12:30 p.m. Staff B confirmed she was Client 1's ISP from 6:30 a.m. to 10:30 a.m. on 10/13/15. Staff B stated, while at the offsite, she was seated right next to Client 1 while she was shredding papers and did not leave her side. Staff B stated if she noticed something she would have written it down. She stated, "I write down everything." She stated that there was a glass jar on the table that Client 1 used to place the paperclips into. Staff B stated she watched her place the paperclips into the glass jar each time and she was engaged the entire time. Staff C was interviewed on 10/28/15 at 2:35 p.m. Staff C confirmed she was Client 1's ISP from 10:30 a.m. to approximately 2:45 p.m. Staff C stated, while at the worksite, Client 1 was shredding and she "was normal and happy." Staff C stated there was a glass jar where she placed the paperclips. Staff C stated that she did not see anything unusual. Staff E was interviewed on 10/28/15 at 2:45 p.m. and confirmed she provided individual supervision from 7:30 p.m. to 11 p.m. on 10/13/15. Staff E stated Client 1 had no unusual behavior and had no complaints of pain. Therefore, the facility failed to prevent neglect by failing to ensure a safe environment for a client with a known extensive history of self-injurious behaviors that were manifested by swallowing non-food items. There was a noted pattern/trend of multiple similar events in the last 24 months. 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. |
| 630015624 |
Sonoma Developmental Center |
170011244 |
B |
12-Feb-15 |
SJPR11 |
6536 |
T22-DIV5 CH8 ART4 -76525 (a) (20)-Client Rights (a) Each client has the rights listed in (a) of this section which shall not be denied or withheld except as provided in (c) of this section. Each facility shall establish and implement written policies and procedures to ensure that each client admitted is afforded the following rights: (20) To be free from harm, including unnecessary physical restraint or isolation, excessive medication, abuse or neglect. The facility failed to prevent neglect by failing to ensure a safe environment. A client, with severe self-injurious behaviors, self-abusive behaviors, and with a history of ingesting scissors, had scissors in her possession in her bedroom closet and attempted to "stab" staff. The client subsequently turned the scissors toward herself. Client 1 required emergency four (4) point soft tie restraints for 1.25 hours due to continued escalation and combativeness.The facility policy for "Abuse/Mistreatment/Neglect Prevention & Reporting," #413, effective 2/14, contained the following definition of neglect: "Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Any willful act or lack of action that causes or may cause harm which may include but is not limited to failure to provide medical care, mental health needs, assistance with personal hygiene, adequate clothing and nutrition, protection from health and safety hazards,..." On 12/31/14, review of the "Medical History and Review of Systems," dated 10/31/14, indicated that Client 1 had mild intellectual disability, borderline personality (disorder characterized by instability in moods, interpersonal relationships, self-image and behaviors), PTSD (Post Traumatic Stress Disorder), impulse control and SIB (self-injurious behaviors). Further documentation indicated that Client 1's self injurious behaviors were manifested by swallowing non-food items which have included scissors (without the handle), requiring surgical intervention, in 3/14 and swallowing keys in 4/14.Client 1's "Behavior Support Plan," dated 6/26/14, included the following behaviors: "B1-1: Parasuicidal Threats - Threats/statements of wanting to 'harm self' by engaging in SIB (B1-2) with no intent to cause death. B1-2: Parasuicidal - Self Injurious Behavior (SIB)/Pica (craving or ingestion of non- food items) - Cutting or scratching self with sharp objects, cheeks then stores medications for overdose, excessive alcohol ingestion (e.g. mouthwash), ...self- inflicted laceration (s)... or other types of self-injury, including swallowing dangerous objects such as children's scissors, keys, nail clippers, batteries, bottle caps, saran wrap, hand sanitizer, strips of vinyl from furniture, or metal / plastic pieces." Review of the "Individual Supervision Guidelines," dated 12/23/14, indicated Client 1 would be on individual supervision on all shifts, at all locations, due to concerns about her medical safety and stability. Individual supervision was defined as follows: "Staff must be able to see their assigned client at all times and be in close enough proximity to protect them and others from injury..." On 1/14/15, review of the GER (General Event Report), dated 12/30/14, indicated Client 1 had been intermittently refusing meals and her primary intake had been caffeinated products. Documentation indicated Client 1 exhibited signs/symptoms of forgetfulness, weakness, and an unsteady gait. Interdisciplinary Notes, dated 12/30/14, indicated at 9 a.m., a special meeting was held to discuss Client 1's Denial of Rights (DOR). The DOR was initiated to restrict access to caffeinated items and allow for search of Client 1's person and room to ensure that there was no caffeine in her possession. After the meeting, staff searched and confiscated all of the caffeine products in Client 1's room. While Client 1's 1:1 (one staff/one client supervision) was attempting to keep Client 1 busy with other things, Client 1 heard staff in her room and pushed through into her room and refused to let staff take her caffeinated items. Documentation indicated that Client 1 was very upset when the last items were being removed and she "lunged" into her cabinet, retrieving a large pair of metal scissors. Client 1 attempted to stab a staff, cutting her right hand, and then turned the scissors toward another staff. When attempts at harming the staff were not successful, she inverted her wrist and turned the scissors towards her own chest, attempting to push the scissor into her chest. Staff was able to remove the scissors from Client 1's hands and threw them out of the way.When police arrived, Client 1 continued to fight, kick, and attempted to bite staff. Client 1 was placed in soft ties. Client 1 refused to walk with staff into the safe room. A blanket pull to room 129 was performed with eight (8) staff, where the client was lifted into bed, and was placed in 4-point soft tie restraints from 11 a.m. to 12:15 p.m.Client 1 was provided with two female licensed staff and was placed on suicide watch due to attempting to stab herself. During an interview with the Director of Quality Assurance, Staff B, on 12/31/14 at 9:45 a.m., Staff B stated that Client 1 should not have had scissors in her room. During an interview with supervisory staff, Staff C, on 12/31/14 at 10:45 a.m., Staff C described the scissors as "very sharp shears." On 1/7/15 at 10:18 a.m., during an interview with Staff D, who Client 1 initially alleged had given her scissors, denied giving scissors to Client 1. Staff D stated that she was familiar with Client 1's behavior plans and stated, "I know she can't have sharp objects, she swallows it or will stab." During an interview with supervisory staff, Staff E, on 1/14/15 at 11:15 a.m., Staff E stated that she was present during the client's interview with the Office of Protective Services and Client 1 would not say where she obtained the scissors. During a subsequent interview with Staff E on 1/27/15 at 8:58 a.m., Staff E stated that Client 1 said that she did not remember anything, only that it was a female. Therefore, the facility failed to prevent neglect by not ensuring a safe environment when a client, with a history of severe self-injurious behaviors, and a history of ingesting scissors, obtained and hid sharp scissors, accessed them from her bedroom closet, harmed staff and attempted to harm herself with the scissors. The above violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 220000416 |
Seton Medical Center |
220008904 |
AA |
12-Jan-12 |
S8SJ11 |
12034 |
F328 483.25 (k) TREATMENT/CARE FOR SPECIAL NEEDS The facility must ensure that residents receive proper treatment and care for the following special services: Injections; Parenteral and enteral fluids; Colostomy, ureterostomy, or ileostomy care; Tracheostomy care; Tracheal suctioning; Respiratory care; Foot care; and Prostheses. This Requirement is not met as evidenced by: Based on interview and record review the facility failed to ensure one patient who had a tracheostomy (Resident A) received proper respiratory care when: 1. There was no documented evidence of Resident A's oxygen saturation (SaO2) levels on 6/22, 6/23, and 6/24/11 to ensure it was maintained at or greater than 93 %. 2. The facility failed to maintain the resident's airway patent when a staff (LVN 1) did not remove the cap from the expiratory port of a T-piece which is a part of a medical device known as the KimVent Turbo-Cleaning Closed Suction System attached to Resident A's tracheostomy tube. The deficient practice caused the death of Resident A on 6/24/11 due to asphyxiation as a result of obstruction of the tracheostomy tube. Findings: Resident A, an 81 year old female was admitted to the facility on 11/12/09 for ongoing management of chronic respiratory failure with a tracheostomy ( surgical breathing hole in neck).Record review of Resident A's History and Physical Report dated 11/12/09 indicated she had a history of CVA (cerebro-vascular accident or stroke). Resident A was not responsive to verbal stimuli and was in a persistent vegetative state (wakeful unconscious state that lasts longer than a few weeks). Resident A's eyes would open but she was not alert or oriented and was unable to communicate or follow commands. The patient was breathing spontaneously via a tracheostomy tube. She required a tracheostomy (a breathing tube surgically inserted into the neck) for protection of her airway. She was totally dependent on staff for her activities of daily living. According to the annual Minimum Data Set (MDS) dated 11/15/10, and the latest quarterly MDS dated 5/15/11, under Special Treatments, Procedures and Programs, the following Respiratory Treatments were performed on the patient: oxygen therapy, suctioning and tracheostomy care.Record review of a Nursing Care Plan, dated 11/12/10 and updated on 1/19/11, indicated: "Problems...Impaired airway clearance related to tracheostomy and respiratory failure, Goal: Resident's airway will remain patent X 90 days- as evidenced by a SaO2 above 93%" (oxygen saturation-a measurement that indicates adequate oxygen is being taken into the body for life, measured by a bedside device). According to the Nursing Care Plan updated on 4/19/11, it indicated under Needs/ Problems section that Patient A had potential problem for aspiration secondary to presence of tracheostomy and tube feeding. The Action Plan was to: Auscultate lungs q (every) shift and prn (whenever necessary), Report changes in lung sounds to MD, ..." Record review of Treatments Sheet for 6/1/11- 6/24/11 indicated a treatment order dated 11/12/09 to "suction q (every) 2 H (hours) and prn. It also indicated an order to "Keep SaO2 at 93% or greater at all times." and "Trach. care Q (every) shift and prn (when necessary)..." Record review of Resident A's Long Term Clinical Care Flowsheet for 6/21/11, 6/22/11, 6/23/11, and 6/24/11 indicated that the box for recording the SaO2 was left blank. There was no documented evidence that nursing staff had checked Patient A's SaO2. In an interview, on 10/6/11 at 11 A.M., the Risk Manager 1 (RM 1) and the Chief of Respiratory Therapy acknowledged that the nursing staff did not routinely measure Patient A's SaO2 on 6/22/11, 6/23/11, and 6/24/11 before this reported incident. Record review of a Physician Progress Note for Resident A, dated 6/16/11 indicated, "Subjective: The patient does not respond to stimuli. Objective: Vital Signs...blood pressure 116/68...Chest: No wheezing... Assessment: Respiratory failure, tracheostomy, gastrotomy, no ventilator dependency..." Record review of Progress Notes dated 6/24/11 at 3:23 P.M., indicated: "RN 1 called to inform that patient was found pale, non-responsive, Vital Signs (blood pressure and pulse) could not be appreciated, no spontaneous breathing. Rapid Response team called , but canceled due to patient's DNR (do not resuscitate)." Record review of a Physician Progress Notes, dated 6/24/11 at 6:25 P.M., indicated: "Called by nursing staff to pronounce patient who they say died at 3:15 P.M.. Patient is in fact dead with dilated pupils no respiratory effort and is pulseless. A T-piece is attached to a tracheostomy. The expirator port is occluded with a plastic cover." In an interview, on 7/15/11 at 11 A.M. the facility's RM 1 provided a summary of the reported adverse event as follows: "On 6/24/11 at 3:15 P.M. LVN 1 (Licensed Vocational Nurse) went into Patient A's room to change the T-piece suction set up attached to the tracheostomy. The T-piece is a closed device that is attached to the tracheostomy for suctioning (method of removing secretions that accumulate in the lungs and wind pipe). Patient A was not on a ventilator (breathing machine) but was breathing humidified air and oxygen through this T-piece on her own. When the T-piece comes in the package for changing it comes with a cap on the expiration port. The cap must be removed prior to use when the patient is breathing on her own. Essentially, LVN 1 did everything right except she left the cap on. She said she took the cap off. When another nurse (LVN 2) came in to check on Patient A , she saw the cap was on the T-piece expiration port and the patient was not breathing on her own. LVN 2 immediately removed the cap and began bagging ( device used to provide rescue breathing ) the patient. Patient A never started breathing on her own again...since she was DNR, she was pronounced dead." In an interview on 7/15/11 at 11:30 A.M., Respiratory Therapist 1 (RT 1) (a respiratory therapist helps evaluate, treat and assist the health care team with patients with respiratory disease) who assisted LVN 2 in the above described incident was asked if Patient A was a spontaneously breathing patient. RT-1 said, "Patient A was not on a ventilator. She was breathing on her own. The white cap should have been off of the T-Piece. There should have been a little plastic tube connected to the T-piece so the patient could exhale." In an interview on 7/15/11 at 12:27 P.M., LVN 1 was asked about changing the T-piece on Patient A. LVN 1 said, "I remember coming in to Patient A's room with LVN 3 at about ten minutes to three to change the T-piece. The T-piece was used to suction the patient through a trach (tracheostomy), we change it every three days. Since this patient was on oxygen and breathing on her own we took the white cap off. I remember changing the T-piece. Everything was all right with the patient when I left the room." LVN 1 was then asked if she remembered who took the white cap off of the T-piece expiration port. LVN 1 said, "Honestly, I can't remember." In an interview on 7/15/11 at 1:15 P.M., LVN 2 who discovered Patient A was not breathing on 6/ 24/11, was asked to describe what happened. LVN 2 said," It was a Friday at about five minutes to 3 P.M., I was going on my rounds and checking on Patient A in her room. Looking at her I did not think she was breathing. I shook her and I saw right away that the T-piece had a cap on it and she was not breathing so I called for help, took the T-piece completely off and started bagging her." The surveyor asked LVN 2: "When you took the T-piece off the tracheostomy of Resident A, was the white cap on or off ?" LVN 2 said, "That cap was on, it should have been off." LVN 2 was asked what would happen to the patient if the cap was left on. LVN 2 explained, "If the white cap was left on, the patient cannot exhale and breathe on her own." Review of Resident A's San Mateo County Coroner's Office combined Autopsy Report and Pathology Report dated 8/31/11, indicated: "Conclusion: The cause of death listed was asphyxiation due to obstruction of tracheostomy tube. Patient A was in a persistent vegetative state after suffering a cerebral vascular accident in 2009...Patient A was a patient at the hospital...On Friday, June 24, 2011 at approximately 1500 hours (3 P.M.), the subject's tracheostomy tube was replaced, but the cap was not properly removed preventing oxygen to the subject. Based on information obtained in the Coroner's Investigation Report and Autopsy Report, I have determined that the manner of death to be an accident." Review of the manufacturer's directions for use of the Kimberly-Clark KimVent Turbo-Cleaning Closed Suction System dated 2007, indicated: "Warning: Cap on KimVent T-Piece prevents continuous flow therapy (oxygen is administered through a tube to a breathing patient with a tracheostomy). Remove cap before starting continuous flow therapy. Failure to remove cap prior to continuous flow therapy may result in serious injury or death."Review of the LVN 1's competency Action Plan, dated 5/2/11, indicated : "In-line Suction Catheter/White Cap Set-up... Ensure all licensed Respiratory Care Practitioners and licensed Nursing personnel on the Subacute Unit clearly understand the two different set -ups, for the in-line suction catheter when used with a ventilator and when used on a spontaneously breathing patient i.e.,without a ventilator. Additionally, ensure the aforementioned staff understands why the white cap is not to be placed on the in-line suction catheter when the patient is not on the the ventilator."In an interview, on 10/5/11 at 11:30 AM, the Chief Respiratory Therapist was asked if there was a facility policy and procedure that described the training and the operation of the Kim Vent T-piece device. The Chief Respiratory Therapist said, " No, I checked with Nursing. The only policy is the Action Plan competency check list that Respiratory Care uses to train the nurses who use the KimVent."In a phone interview, on 9/15/11, the Kimberly Clark manufacturer's clinical care representative was asked to explain why the white cap needed to be removed from the T-piece part of the Kimberly-Clark KimVent Turbo-Cleaning Closed Suction System when it was used on a spontaneously breathing patient. The clinical care representative said, "When the patient is breathing on her own through the T-piece, if the white cap is not off the patient cannot exhale. It is like suffocating the patient." In a phone interview, on 9/27/11 at 2:44 P.M., LVN 3 was asked what she remembered about changing Patient A's T-Piece on 6/24/11. LVN 3 said, "LVN 1 asked me to help her change the tubing. LVN 1 handled the T-Piece. I was in the back of the bed changing the oxygen tubing and water bottle. LVN 1 was in front of Patient A. I handed her the tubing and she connected to the T-Piece. Then she connected it to Patient A. I then left the room. LVN 3 was then asked if she had removed the white cap from the T-Piece. LVN 3 said, "No." LVN 3 was then asked if LVN 1 had removed the white cap from the T-Piece. LVN 3 said,"I don't remember. Patient A was breathing on her own when I left the room."The facility failed to ensure that Patient A who had a tracheostomy, received proper respiratory care when:1. There was no documented evidence of Patient A's oxygen saturation (SaO2) levels on 6/22, 6/23, and 6/24/11 to ensure it was maintained at or greater than 93%. 2. The facility failed to maintain the resident's airway patent when a staff (LVN 1) did not remove the cap from the expiratory port of a T-piece which is one part of a medical device known as the KimVent Turbo-Cleaning Closed Suction System attached to Patient A's tracheostomy tube. The deficient practice caused the death of Patient A on 6/24/11 due to asphyxiation as a result of obstruction of the tracheostomy tube. The facility's failure presented an imminent danger to the patient and was a direct proximate cause of death of the patient. |
| 220000955 |
STEPHANIE'S ICF/DDN |
220009302 |
B |
15-May-12 |
DWW311 |
11530 |
T22 DIV5 CH8 ART 4-76525(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. This regulation was not met as evidenced by: The facility failed to: 1. Ensure that Client 1 was free from neglect and verbal and mental abuse during Direct Care Staff 1's (DCS 1) care. 2. Investigate Client 1's complaints of neglect and verbal and emotional abuse when they became aware of them. Client 1, who had cerebral palsy and was alert and oriented and able to make his needs known, told staff that DCS 1 was rough during care, nasty, and very mean to him. He said DCS1 yanked his arms, called him names, belittled him and let him lie for hours before changing his diaper. He said this made him feel humiliated and afraid. Even though Client 1 told staff about DCS1's care, staff failed to investigate Client 1's concerns and to provide a safe environment to ensure that Client 1 was free from neglect and verbal and mental abuse.Client 1 was admitted to the facility on 4/7/10 with diagnoses including cerebral palsy, asthma, diabetes, depression and bowel infection. The Comprehensive Functional Assessment, updated 7/8/10, indicated that on 4/9/10, Client 1's evaluation showed he was alert and oriented, verbal, answered questions appropriately, could hear and see well, was non-ambulatory, non-weight bearing, and incontinent of bowel and bladder. He had "very poor control of his extremities," and was "unable to help with transfers from bed to wheelchair." He was "very jolly, well-liked, sociable and easy to get along with, able to express his wants and needs, was a smart guy who can easily follow directions and commands," and "signs for his (legal) consents."Review of Client 1's 4/9/10 Client Plan of Care showed his "Problem/Needs" were, "Altered elimination pattern related to incontinence on both B/B (bowel and bladder) functions." The "Objective/Goals" was "Client will remain clean, dry and odor free." The "Approaches" included, "Provide pericare every day after incontinent episodes," Provide cheerful dialogue with client while cleaning to encourage/maintain self-esteem," and "Check for wetness every 2 hours." The 6/28/10 "Client Plan of Care" showed the "Problem," "Frequent episodes of diarrhea."Review of the "Meds" sheet, dated 6/15/10 to 7/15/10, showed Client 1 had a physician's order for, "Immodium 4mg after each episode of diarrhea," for which he received doses on 6/28/10 and 6/29/10.Review of Client 1's Nurses' Notes, dated 7/18/10 from 8:00 AM to 4:00 PM, indicated, "Large, soft stools noted." The record did not indicate the number and frequency of stools.Review of Client 1's Nurses' Notes, dated 7/19/10 at 6:12 AM indicated Client 1 was, "Noted client to be vomiting." At 6:35 he "had another vomiting episode," his blood oxygen saturation level was 90% to 92% , and he was transferred to the hospital.Review of a "Special Incident Report," dated 8/6/10, indicated, "The social worker went to the (hospital) on 8/6/10 to visit Client 1, whom (sic) was hospitalized on 7/19/10 for internal infection. Client 1 stated several times that he did not want to return back to his group home. Social worker asked Client 1 why he didn't want to go back to (the facility). According to Client 1, his hygiene needs were not met there. On several occasions Client 1 requested to the night staff at (the facility) that he needed a diaper change, but they would ignore him. Client 1 was unsure how many times this occurred, but he thinks around 5 times. Client 1 stated that the last incident occurred right before his hospitalization on 7/19/10....Social worker will be reporting incident to Ombudsman Office, Department of Health Care Licensing, and will be looking for alternate placement for Client 1." In interview on 8/24/10 at 9:30 AM, Licensed Vocational Nurse 1 (LVN 1) said Client 1 was transferred to the hospital due to vomiting, and he had C-difficile (bacteria that causes diarrhea). LVN 1 said when a Regional Center social worker visited Client 1 in the hospital on 8/6/10, Client 1 complained about Direct Care Staff 1 (DCS1), and Client 1 said he did not want to return to the facility because he did not feel comfortable with DCS1. LVN 1 said a meeting was held at the facility on 8/7/10 with the Ombudsman, LVN 1, Registered Nurse 1 (RN 1) and DCS 1 to discuss ways DCS 1 should approach Client 1. LVN 1 said RN 1 told DCS 1 to use a lower tone of voice when talking to Client 1, because DCS 1 sounded mad. LVN 1 said the Administrator was aware of Client 1's complaint on 8/7/10, but the facility had not conducted an investigation.The Nurse's Notes, dated 8/7/10 from 8:00 AM to 4:00 PM, showed Client 1 remained at the hospital. There was no documentation of Client 1's complaint about DCS 1 to the Social Worker, and no documentation of a meeting between the Ombudsman, LVN 1, RN 1, and DCS 1 to plan approaches to Client 1.In interview on 8/24/10 at 10:10 AM, the Qualified Mental Retardation Professional (QMRP) said she interviewed Client 1 and he told her that DCS 1 did not change his diaper. The QMRP said Client 1 told her DCS 1 was, "mocking me because I did number two (bowel movement)." The QMRP said, "We usually investigate complaints, but there is no documentation." When interviewed on 8/24/10 at 10:20 AM, the Administrator acknowledged that no investigation had been conducted about Client 1's complaints about DCS1. During an interview on 8/24/10 at 11 AM, RN 1 stated LVN 1 told her that Client 1 was not comfortable with DCS 1 because DCS1, did not "change me when I'm wet." RN 1 said a meeting was held on 8/18/10 in Client 1's hospital room with Client 1's primary care Physician, the facility Administrator, the Social Worker, LVN 1, the QMRP, and RN1. RN1 said Client 1 stated, he "doesn't want to live here (in the facility)." RN 1 said no investigation regarding Client 1's complaints about DCS1 was done by the facility. Review of Client 1's Nurse's Notes, dated 8/18/10 at 2:10 PM, indicated, "Visited by PMD (primary physician), SW (Social Worker), QMRP & RN 1 consultant to discuss placement in a SNF (skilled nursing facility) upon discharge." There was no documentation in the record of Client 1's complaints about DCS 1, or Client 1's refusal to return to the facility when discharged.In an observation at the hospital on 8/25/10 at 8:45 AM, Client 1 was sitting up in bed, alert, oriented and conversant.In an interview at the same time, Client 1 stated, "They let me wait for three to four hours before changing me a lot of times, mostly at night. They pulled me up by my arms, straight up, and hurt me. It was the same person, a man. He called me names. He said, 'you s--- in your pants. You smell like s--- He was nasty, very mean. It happened on the night and day shift. He told me I had to wait my turn. He yanked my arms. He was rough with me in the bathroom. He'd run the water too cold and too hot. He'd scrub my head with a head brush. I told (DCS 1) it hurt. He (DCS 1) said that I'm just a baby. I told (Social Worker) when he came to the hospital. He (DCS 1) made me feel awful, like I was dirt. He told me, 'All you do is s--- in your pants. You smell." When asked if he was afraid of DCS 1, Client 1 stated, "Yes. I knew I had to tell (Social Worker). I can't take it anymore. (Social Worker) told me I don't have to go back there any more. He's going to get me another place to live." When asked if he told any staff at the facility about DCS 1, Client 1 stated, "I knew they wouldn't do anything. I told (LVN 1) I didn't want to live there. He gave me a bunch of excuses. I told (LVN 1) that (DCS 1) would let me lie there for hours before changing my diaper, that (DCS 1) would take the bed and shake me, and that the (staff) would be talking in (a non-English language) to each other. I didn't know what they were saying. (LVN 1) told me, '(DCS 1) had other people to take care of.' (DCS 1) did what he wanted. I told (DCS 1) I did not like him and he laughed. I hope I do not have to go back. I've had enough of that guy." In an interview on 8/25/10 at 1:05 PM, DCS 1 said, "I worked from 5:00 AM to 8:00 AM and 2:00 PM to 8:00 PM. The Administrator told me that Client 1 complained that I did not change his diaper. When Client 1 told me he was wet, I would say, 'Wait. I'm with others. I need to change them first, because they go to the day program.' Client 1 complained. Client 1 has six to seven BMs (bowel movements) in two to three hours. He gets a shower on the gurney. When I moved him, he would say, 'Ouch.' I said to him, 'Maybe you miss your wife; that's why you say 'Ouch.' I would tell Client 1, 'Why are you saying, 'Ouch? I did not hurt you. Maybe, its because you miss your wife." Review of the facility's undated policy entitled, "Client Abuse," indicated, "Any employee found abusing, harassing, or intentionally mistreating a client shall be discharged immediately." The policy stated common causes of client abuse were, "Ignoring client and showing others more attention, Withholding services, Making sarcastic remarks, Being rough in dressing, bathing, or undressing of resident," and "Not providing routine services." The policy also stated, "Upon report of any allegations or violations the Administrator or his/her designated representative will thoroughly investigate the situation. Any employee suspected of abuse or neglect will be removed from direct care of the resident/residents while the investigation is in progress. The policy's Examples of Physical and Emotional Abuse included, "Inappropriate verbal encounters (verbal abuse) such as the use of obscenities or profanity in the presence of, or belittlement." The policy's Examples of Neglect included, "Intentionally neglecting to bathe or change a resident." In an interview on 2/2/11 at 9:30 AM, LVN 1 said Client 1 did not like DCS 1 because DCS 1 always seemed mad and talked in a loud voice. LVN1 said Client 1 was verbal and able to tell when he needed a diaper change, and Client 1 had frequent BMs after his hospitalization on 6/10/11. DCS 1 was the only male and mostly took care of Client 1.In an interview at the same time on 2/2/11 at 9:30 AM, the QMRP said Client 1 had diaper changes constantly. Since Client 1 was not going to the day program, other clients were taken care of first. The facility had three direct care staff and one LVN to take care of five clients. The QMRP said while Client 1 was in the hospital, they offered to let LVN 1 take care of Client 1 when he came back to the facility, but Client 1 said no. The QMRP did not explain why the facility did not investigate Client 1's complaints about DCS1's roughness and calling him names during care, and why they did not ensure that Client 1 was free from neglect and abuse. Therefore, the facility failed to: 1. Ensure that Client 1 was free from neglect and verbal and mental abuse during Direct Care Staff 1's (DCS 1) care. 2. Investigate Client 1's complaints of neglect and verbal and emotional abuse when they became aware of them. The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety or other emotional trauma to patients. |
| 220001048 |
SUBACUTE/SARATOGA |
220009515 |
A |
25-Sep-12 |
ITJW11 |
7676 |
F333483.25(m)(2) RESIDENTS FREE OF SIGNIFICANT MEDICATION ERRORS The facility must ensure that residents are free of any significant medication errors. This regulation was not met as evidenced by: Based on interview and record review, the facility failed to ensure a medication was administered as prescribed for one (Resident A) of one sampled resident. For Resident A, an excessive amount of a muscle relaxant medication (Baclofen) was received, resulting in a clinically evident overdose, and Resident A was transferred to an emergency room service.Findings: On 12/29/10 at 2:55 PM, Resident A received a clinically evident overdose of a muscle relaxant medication (Baclofen) during refilling of the Intrathecal Baclofen (ITB) pump when the medication entered the side port (the infusion port) instead of the reservoir port and the medication was injected into the resident intrathecally (infused into the membranes of the central nervous system) instead of being stored for gradual administration by the pump. Resident A became unresponsive and had decreased blood pressure, temperature, heart rate and respirations. Resident A was sent to an acute care hospital, emergency room service.Resident A was admitted to the facility on 5/12/08 with diagnoses including brain injury, and cerebral palsy (a loss of motor control with involuntary muscular contraction and/or spasms caused by permanent brain damage). Resident A had developed spasticity (a state of increased muscular spasms). The 12/30/10 Minimum Data Set (MDS, a resident assessment) indicated Resident A had severely impaired decision making ability and needed total staff assistance for all care.Record review of Resident A's 12/06/2010 Physician's Orders indicated: "ITB (intrathecal baclofen) simple continuous 473 mcg/day (micrograms per day)."Record review of Resident A's Medication Administration Record (MAR) for December, 2010, indicated Resident A received ITB as prescribed at 473 mcg/day continuously from 12/6/10 through the evening shift of 12/29/10. The MAR also indicated the ITB was on hold during the 12/30/10 night shift. There was no documentation on the MAR to indicate when the ITB reservoir was refilled and who did it. Review of Resident A's Progress Record, dated 12/29/10 at 2:55 PM, indicated, "Resident MD try to refill baclofen pump. Another RN... present at bedside with Resident MD. Before the baclofen pump refill (ITB) procedure, patient alert and awake, open eyes, vs (vital signs) stable. During the baclofen pump refill procedure, patient LOC (level of consciousness) changed. (L) eye closed, not waking up to touch. ...BP (blood pressure) 82/51 (reference range 120/80)...O2 Sat (oxygen saturation) 96% (reference range above 90%) RA (on room air), T (temperature) 96.6 F (Fahrenheit- reference range 98.6), RR (respiratory rate) 14 (reference range 14 - 20), HR (heart rate) 54 (reference range 60 - 100)..." Addition, at 3:15 PM, Resident A's BP dropped to 77/41, the HR dropped to 48 and one liter of normal saline was administered intravenously (IV).Review of Resident A's Progress Record, dated 12/29/10 at 3:30 PM, indicated, "BP 91/69...RR 4, O2 Sat 88%..... RT (Respiratory Therapist) bagged the patient with 100% O2. RT place the patient on vent (ventilator)."Review of Resident A's Progress Record, dated 12/29/10 at 4:30 PM, indicated, "Procedure: Baclofen pump refill. ...It was determined that we were likely in the side port (the infusion port). Therefore the 8 cc (centimeters = milliliters (ml) of 2000 meq/ml (milli-equivalents per milliliter) was injected intrathecally (infused into the membrane of the central nervous system for a suspected total of 16000 meq in 8 ml at one time instead of gradual administering by the pump at the rate of 473 mcg/day). The fluid that was pulled out was completely clear, not suggesting CSF (cerebrospinal fluid). The procedure was halted, pump was reinterigated (sic) (reinterogated- checking the reservoir volume registered by the pump) showing reservoir volume of 3 ml. This confirms either a subq (subcutaneous) or intrathecal injection. The pt (patient) was placed on close observation, vent was brought into room for resp (respiratory) support. He was noted to have decreasing temp, decreasing BP, which bottomed out at 71 SBP (systolic blood pressure). 2 peripheral IVs were started & ... bolus NS (normal saline) was given. His BP returned to 103 SBP. He continued to be sedated, his tone significantly decreased." Review of Resident A's physician's note, dated 12/29/10 at "Time 3-8 PM" indicated, "Pt (patient) received overdose of ITB amt (amount) unknown...Amt enough to make (Resident A) unresponsive with decreased respiratory excursions...BP...below his normal...given N/S (normal saline) with restoration of BP to his baseline...Remains unresponsive..." Addition, the physician's impression was, "ITB overdose- clinically evident - all VS (vital signs) stable and at baseline. Continue to monitor closely." Review of Resident A's Physician's Orders, dated 12/30/10 at 3:00 PM indicated, "Transfer to hospital ER (Emergency Room) for further eval (evaluation)."Review of Lexi-Drugs Online (http://online.lexi.com/crlsql/servlet/crlonline?doc&bc=patch_f&mn=&id=6414&mid=... 10/18/2011; copyright (c) Lexi-Comp, Inc. 1978-2011) information about Baclofen indicated an adverse effect of Baclofen was that it may cause "Central nervous system: Drowsiness, vertigo, psychiatric disturbances, insomnia, slurred speech, ataxia, hypotonia; Neuromuscular and skeletal: Weakness." Addition, a high alert medication indicated, "Heightened risk of causing significant patient harm when used in error." Review of Resident A's 11/1/08 Long Term Care Plan (Care Plan) for, "Potential for Overdose/Withdrawal of ITB," indicated the Interventions, "Give ITB per MD (Medical Doctor). Monitor for signs of overdose: drowsiness/dizziness, coma, lethargy, lightheadedness, breathing slowly/respiratory depression, hypotension, and seizure."During an interview on 1/12/11 at 12:00 PM, the Director of Nurses (DON) stated Resident A was overdosed by a muscle relaxant medication (Baclofen) during refilling and re-setting of ITB pump (intrathecal Baclofen, a surgically implanted infusion pump that directly delivered medication to the central nervous system) by Physician 1 (a resident physician) and Registered Nurse (RN) 1 on 12/29/10. DON also stated RN 1 was not certified by the facility by an in-service training in the procedures to use and refill the ITB pump; Resident MD did not have document to show competence to refill the ITB without supervision. During the re-filling process, the medication was accidently entered into the side port (the infusion port) instead of the center port (The center port is a reservoir port for re-filling the side port under a pre-set timing and a pre-set amount of medication for infusion into the resident). In addition, DON stated Resident A became unresponsive, had difficulty breathing, and was transferred to ER on 12/30/10 and admitted to an acute care hospital. DON also stated on 12/29/10, the facility had no policy and procedure for administering ITB pump.Therefore, the facility failed to ensure that medication was administered as prescribed when Resident A received an excessive amount of a muscle relaxant medication (Baclofen), resulting in a clinically evident overdose, and was transferred to an acute care hospital, emergency room. The above violations either jointly, separately, or in any combination presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 220000084 |
SEQUOIAS SAN FRANCISCO CONVALESCENT HOSPITAL |
220010147 |
A |
17-Sep-13 |
ULUI11 |
6186 |
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. This regulation was not met as evidenced by: The facility failed to provide the proper supervision through appropriate care planning, and implementation to minimize the risk of injury to Resident 1 with a high risk for falls. Resident 1 was admitted to the facility on 8/18/09 cognitively intact by interview scoring assessment. The resident was assessed to be at a very high risk for falls, with an interview-based score of 38, with greater than 16 placing an individual at high risk for falls. Initial care planning by the facility was to include a one person physical assistance to perform the Activities of Daily Living (ADLs), including transfers, ambulation, dressing, eating, toileting, and personal hygiene. The resident required stabilizing physical assistance when transferring or changing position. There was significant weakness noted on one upper extremity.Resident 1 was diagnosed as having atrial fibrillation, bradycardia, coronary heart disease, and hypertension. His medications for these conditions included lisinopril 40 mg every day, carvedilol, and amlodipine all are associated with a potential side-effect of postural hypotension (a dropping of the blood pressure associated with a change of position) in the manufacturer's printed material. Care should be taken to allow the blood pressure to stabilize before standing or ambulating is initiated. The facility did include the following things in their care planning: 1) continued assessment of contributing problems; 2) PT/OT screening evaluation; 3) need for the head of the bed to be up for breakfast, not sitting on side of the bed; 4) call bell always within reach of resident; 5) PT program for gait training; 6) side rails up at all times; &) notify family and physician of changes; and 8) instruct the resident to call for assistance with any transfers or ambulation. On March 7th, 2012 at 7:20 AM, the resident was eating breakfast, sitting on the edge of the bed. The Certified Nursing Assistant (CNA) heard a loud crash from the resident's room, and found the resident lying on the floor with broken glass (from the dishware and glassware used for food service) all about. There were apparent injuries to the anterior aspect of his body including his face and a deep laceration over the right forearm into the muscle with significant hemorrhage at the site. The paramedics were called, and the resident transported to the acute care hospital, where the lacerations were treated. The resident required two units of packed red blood cells to correct the loss from the injuries.On March 22nd, 2012 at 4:05 AM, the resident was found lying on the floor next to his bed, having taken off his alarm device (to detect movement) and his Continuous Positive Air Pressure breathing device (CPAP). A scalp laceration was noted. The resident was transferred to an acute care hospital, where the head laceration was closed. A CT scan of the head was performed and it revealed an acute subdural hematoma in the area of the laceration. A neurosurgery consultation was obtained, and it was recommended to the family that this hematoma was life-threatening and needed to be drained. After consideration of the resident's condition, the family elected not to proceed with that treatment. The resident expired on April 8th, 2012, with a diagnosis of accidental death due to head trauma with subdural hemorrhage suffered in a fall. During an interview with C.N.A.1 on 10/22/12 at 3:55 PM, she was asked to describe Resident 1's fall incident on 3/22/12. C.N.A. 1 stated, "I'm working the night shift. I don't remember the date. To my shift, he (Resident 1 ) fell around 3:30- 4:30 AM. I stay with him by the door. He tried to get up. I called my charge nurse. She helped me and he sit by the bed. He said, "I want to lay down." He closed his eyes. I went to answer the call light. I did not tell to my charge nurse because I saw him sleeping. When I came back, I saw he fell. I told my charge nurse. I called her. He is alert. There is blood in the head." During an interview with Charge Nurse 1 (CN 1) on 10/25/12 at 9:00 AM regarding the fall incident on 3/22/12, she stated that, "I saw C.N.A. 1 going from Resident 1's room. I was giving meds. My med cart was just 3 rooms away. I asked C.N.A. 1 where Resident 1 was. She said, "He's asleep." In an interview with the Director of Nursing (DON) on 10/19/12 at 4:55 PM, the DON acknowledged that there was no evidence that the physician was notified, or was there a treatment order to address Resident 1's change in behavior exhibited by increased restlessness and agitation on 3/21 and 3/22/12. The DON acknowledged that there was no evidence that on 3/22/12, the charge nurse requested for additional staffing to provide continuous monitoring and supervision for Resident 1, who has history of multiple falls, was restless and agitated, who knew how to remove his tab alarm, and made several attempt to get out of his bed. Therefore, the facility failed to provide the proper supervision through appropriate care planning and implementation to minimize the risk of injury to Resident 1 with a high risk for falls. The facility had a duty owed to the resident to provide a safe environment, and to continually provide an appropriate plan of care to assure that environment, as established by the regulation cited. The facility failed to satisfy that duty through appropriate care planning and execution of that care plan to minimize the chances of injury due to falls. The resident did suffer two significant falls in the month of March, 2012, which caused severe lacerations requiring a blood transfusion, as well as the creation of a subdural hematoma. The hematoma was not treated per family's informed decision, and the resident expired as a result of his injuries. The violations either jointly, separately, or in combination presented an imminent danger that death or serious physical harm would result. |
| 220000416 |
Seton Medical Center |
220010970 |
B |
29-Aug-14 |
QH8L11 |
6503 |
F223483.13(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. This REQUIREMENT is not met as evidenced by: The facility failed to ensure that one sampled resident (Resident 1) was free from abuse, when, a Certified Nurse Assistant (CNA 1) touched Resident 1's breasts in an inappropriate manner on 11/19/13. This failed practice resulted in Resident 1's feeling very upset, insulted and angry.Findings:During review of the History and Physical Form dated 6/12/12, it indicated that Resident 1 was admitted to the facility on 6/12/12 with the diagnoses including dementia (is a general term for a decline in mental ability severe enough to interfere with daily life) and urinary tract infection (an infection in any part of the urinary system -- kidneys, ureters, bladder and urethra). The Minimum Data Set (MDS- an assessment tool) dated 10/23/13, indicated that Resident 1 was able to hear with no difficulty, had a clear speech, able to make herself understood and usually understood others.A review of the facility document titled: "Progress Notes" of the Social Service Aide (SSA) dated 11/22/13, "Subject: Suspected abuse - late entry, indicated, Reported by nursing that (name of staff), CNA (Certified Nurse Assistant), was observed putting her hands on resident's breasts (Resident 1's) in an inappropriate manner. The incident occurred on 11/19/13 at approximately 12:00 pm in the Fireside Room during lunch, and witnessed by (name of staff), LVN (Licensed Vocational Nurse) and name of staff (name of CNA). ... ."In an interview with the Nurse Manager (NM) on 12/3/13 at 9:50 a.m., NM was asked what "inappropriate manner" meant, NM stated, "anybody touching area not to be touched. Anybody who approach, (a resident), other than giving care, I have a problem".Continued interview with the NM on 12/3/13 at 10:02 a.m., NM stated that, the incident happened in the TV (Television) Room, there was a camera, it was clear, that CNA 1's action was "more than a friendly behavior". When asked what happened, NM explained that CNA 1 walked in the room towards Resident 1 who was sitting in a wheelchair, CNA 1"reached down" to Resident 1. Resident 1 slapped her (CNA1) away. CNA 1 "laughed", Resident 1 kicked (CNA1) out. CNA 1 started "laughing". When asked if there were other residents in the TV Room at that time, NM stated, about four or five other residents and a total of four other facility staff "who stood by and did not do anything". NM stated that the CNA 1 was terminated following an administrative leave and the other facility staff received disciplinary action.During an interview with the Nurse Manager on 12/3/13 at 10:03 a.m., NM stated, Resident 1 was "very upset, did not eat lunch and did not take her medications after the incident", but, was "fine" now and "later that evening".In an interview with the Minimum Data Set (MDS 1) Coordinator on 12/3/13 at 11:45 a.m., MDS 1 Coordinator stated, Resident 1's primary language was non-English and she responded better with an Interpreter.During an observation and concurrent interview, in the presence of the Interpreter, on 12/3/13 at 11:59 p.m., Resident 1 was awake, sitting on a wheelchair. The Interpreter was asked to inquire if Resident 1 recalled the incident that happened to her on 11/19/13. The Interpreter stated Resident 1 said, "I do remember when the young girl touched my breast". The Interpreter was again asked to inquire how Resident 1 felt when her breast was touched. The Interpreter talked to Resident 1 who stated that, CNA 1 "insulted her (Resident 1)", Resident 1 "felt anger".Review of the document titled: "Patient Care Notes" dated 11/19/13 at 1:00 p.m., it indicated, "TL (Team Leader) notified CN (Charge Nurse) that resident was upset because CNA (initial of the CNA) touch pt breast. I ask TL if she really witness CNA (CNA 1) touch the breast & (and) she said yes & a few other staff that was @ (at) the TV room. I told TL to report it & I will report to Nurse Mgr.(Manager). Reported to Nurse Mgr. (Manager) & she talk to the TL. Pt (patient) (checked mark sign) appears ok". signed by the facility staff.In a phone interview on 8/27/14 at 12:38 p.m., RN 1 was asked to read the Patient Care Notes dated 11/19/13 at 1:00 p.m. RN 1 stated she was the Charge Nurse (CN) on 11/19/13 and was the staff who wrote the note, and signed the note.During a phone interview with Licensed Vocational Nurse 1 (LVN 1) on 8/27/14 at 12:40 p.m., LVN 1 acknowledged she was the Team Leader (TL) who was present during the incident on 11/19/13 at 12:00 p.m. When asked what happened, TL 1 stated, "CNA 1 came hyper, prying, very out going at that moment". TL 1 continued to state, "CNA 1 touched Resident 1's two breasts with her (CNA 1) hand back and forth. CNA 1 stopped for a while, came back and touched Resident 1 again."In a phone interview with Certified Nurse Assistant (CNA) 2 on 8/27/14 at 1:30 p.m., CNA 2 acknowledged he was present in the TV Room during the incident on 11/19/13 at 12:00 p.m. CNA 2 stated that CNA 1 was "holding, tickling" Resident 1's breast. CNA 2 stated that Resident 1 was upset.Review of the facility Policy and Procedure, Abuse, Elder and Dependent Adult, Issue date: 12/93, Revision date: ... 8/13. POLICY: Any Alleged instances of ... or abuse, ... are reported immediately to the Director of Nursing. The Director/designee will notify the ... California Department of Public Health (CDPH) by telephone within 24 hours of the incident. ... The following types of abuse are considered reportable: 5. SEXUAL: Includes ... fondling of breasts ... PROCEDURE: 5. INVESTIGATION, C. If the incident was witnessed, take measures to protect the resident immediately. Remove the resident from the area to a safe place or instruct the individual in question to leave the room or the area. ... ".The facility failed to ensure that one sampled resident (Resident 1) was free from abuse, when, a Certified Nurse Assistant (CNA 1) touched Resident 1's breasts in an inappropriate manner on 11/19/13. This failed practice resulted in Resident 1's feeling very upset, insulted and angry.The above violation either jointly, separately, or in any combination have a direct or immediate relationship to patient health, safety or security. |
| 220000416 |
Seton Medical Center |
220011305 |
AA |
04-Mar-15 |
TXLD11 |
18438 |
Glossary of terms:ACLS: Advanced Cardiac Life Support or Advanced Cardiovascular Life Support; refers to a set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions. ADL's: Activities of Daily Living such as bathing, toileting, dressing and eating Anoxic: without oxygen Asystole: the heart stops beating and there is no electrical activity in the heart. As a result, the heart is at a standstill.Bipolar Disorder: formerly known as manic depression, is a mood disorder that causes radical emotional changes and mood swings, from manic, restless highs to depressive, listless lows. Code Blue: a medical emergency in which a team of medical personnel work to revive an individual in cardiac arrest. Coroner: An official who inquires into the causes of accidental or sudden, unexpected deaths. CPR: Cardiopulmonary Resuscitation; Using rescue breathing and chest compressions to help a person whose breathing and heartbeat have stopped Diabetes: a metabolic disease in which the body's inability to produce any or enough insulin causes elevated levels of glucose in the blood. DNR: An abbreviation for Do Not Resuscitate - a physician's order not to initiate a Code Blue (see Code Blue)Dyspnea: difficult or labored breathing Fenestrated: A fenestrated trach tube is similar to other trach tubes but has one added feature. It has one or more holes in the outer cannula. The holes allow air to pass from the lungs up through the vocal cords and out through the mouth and nose. It allows the patient to breathe normally, speak using vocal cords, and cough out secretions(mucous) through the patient's mouth. Gross aspiration: breathing in a foreign object such as sucking in food into the airway Hypothermic Treatment: active treatment that tries to achieve and maintain specific body temperature in a person for a specific duration of time in an effort to improve health outcomes. This is done in an attempt to reduce the risk of tissue injury such as brain injury from lack of blood flow such as in a cardiac arrest. Hypoxic: a condition in which the body or a region of the body is deprived of adequate oxygen supply ICU: Intensive Care Unit IV: Intravenous Larynx: the voice box Laryngeal (pertaining to the larynx) Edema: A part of acute inflammation of the laryngeal mucosa due to infection, allergy or inhalation of irritant materials. It causes obstruction to air flow, stertor(heavy snoring or gasping), dyspnea(shortness of breath) and potentially asphyxia(suffocation). Morphine Drip: a drip is set up in a machine to deliver a specified amount over a designated time. Morphine is a pain relief medication. Passy-Muir Valve (PMV): a valve that attaches to the outside opening of the tracheostomy to help patients speak more normally. This one way valve attaches to the outside opening of the tracheostomy tube and allows air to pass into the tracheostomy, but not out through it. The valve opens when the patient breathes in. When the patient breathes out, the valve closes and air flows around the tracheostomy tube, up through the vocal cords allowing sounds to be made. The patient breathes out through the mouth and nose instead of the tracheostomy.PEG Tube: Percutaneous Endoscopic Gastrostomy is an endoscopic procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate. Pneumonia: lung inflammation caused by bacterial or viral infection in which the air sacs fill with pus and may become solid. Pt: Patient Prognosis: the likely course of a disease or ailment Schizophrenia: a long term mental disorder involving 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. In general, a mentality characterized by inconsistent or contradictory elements. Tracheostomy (trach): a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube. Tracheostomy Cuff: The purpose of the cuff is to hold the tracheostomy tube in place and prevent the flow of air around the outside of the outer cannula. This allows for more effective ventilation of the patient and prevents the aspiration of liquids into the trachea. Ventilation: breathing Ventilator: a machine that supports breathing F328 483.25 (k) TREATMENT/CARE FOR SPECIAL NEEDS The facility must ensure that residents receive proper treatment and care for the following special services: Injections; Parenteral and enteral fluids; Colostomy, ureterostomy, or ileostomy care; Tracheostomy care; Tracheal suctioning; Respiratory care; Foot care; and Prostheses. This Requirement is not met as evidenced by: Based on interview and record review, the facility failed to ensure that Resident A received proper treatment and care for tracheostomy care when the Passy-Muir Valve was removed from the tracheostomy tube with the cuff still inflated on Resident-A. According to manufacturer's specifications and hospital policy, failure to deflate the tracheostomy cuff while the Passy-Muir Valve is attached would result in an airway obstruction and consequently the patient would be unable to breathe. On 11/15/14, Resident-A was found by the staff in her room pulseless, and without respirations while her Passy-Muir Valve was still attached to her non-fenestrated tracheostomy tube which still had the cuff inflated.Resident-A died on 11/28/14 due to anoxic brain injury secondary to respiratory failure.Findings:Resident-A was admitted from a long term care facility to the hospital on 01/08/14 for management and treatment of pneumonia and respiratory failure. Additional diagnosis included diabetes, bipolar disorder and schizophrenia. Subsequently, Resident-A was placed on a ventilator(a machine that supports breathing) on 01/11/14, and on 01/25/14, the resident had a tracheostomy (a surgical procedure to create an opening through the neck into the trachea (windpipe). The resident was eventually weaned off the ventilator but because of profound swallowing dysfunction, the patient required a permanent tracheostomy. Resident-A did not have difficulties moving her upper extremities on her own but she was unable to walk, and was totally dependent on staff for her ADL's (Activities of Daily Living e.g. bathing, toileting, dressing etc.). Resident-A received all her nutritional support via a PEG tube (a feeding tube through the stomach). Resident-A knew to use the call light for her basic needs but had short term memory deficits and was moderately impaired with decision making She was able to verbally communicate via the Passy-Muir Valve(PMV) which she was able to use daily since 4/24/14. The physician order dated 4/24/14 read, " Pt to wear PMV daily (with) nursing from (7 AM to 11 PM) as tolerated". The resident was stable at her baseline state until 11/15/14. During an interview on 12/02/14 9:45 AM, Staff-1 stated she completed Resident-A's evening care which took about 15 minutes, and left her bedside approximately 8:45 PM on 11/15/14. Staff-1 stated she was confident that she removed Resident-A's Passy-Muir Valve and reinflated the tracheostomy cuff after the evening care. Staff-1 stated she stored the PMV in the resident's night stand drawer which was across the foot of Resident A's bed where it was unreachable by the resident. Staff-1 stated Resident-A was alert and was not in distress when she left the resident's room.During an interview on 12/02/14 at 1:03 PM, Staff-2 who assisted Staff-1 with the Resident-A's evening care on 11/15/14 stated although she did not witness Staff-1's actions, she remembered Staff-1 verbally informing her that she stored the PMV in the resident's night stand and that she reinflated the trach cuff before they left Resident-A's room. Record review on 12/02/14 of the facility's documented staff interviews showed that on 11/15/14 at 8:52 PM, the resident was found unresponsive in her bed. But the Code Blue was not called to the hospital operator until 9:04 PM. During an interview on 12/02/14 starting 9:30 AM, Administrator-1 stated the Code Blue was delayed because the resident's code status was unclear. The hospital policy for patients to wear the Do Not Resuscitate(DNR) purple wrist band was not practiced on the unit hence contributing to the delayed resuscitation efforts of Resident-A.During an interview on 12/02/14 starting 10:17 AM, Staff-3 stated on the evening of 11/15/14, she was asked by another employee (Staff-4) to check on Resident-A who was "not breathing, pulseless & gray colored". Then, Staff-1 entered the room and asked why the PMV was on the resident. At that moment, Staff-3 noticed the trach cuff was inflated so she deflated the cuff. Record review on 12/02/14 of the facility's documented staff interviews showed that Staff-3 stated the following: "She was positive cuff was inflated stated, 'That's my job' ", and, " Asked why she did not start CPR right away since there was no purple DNR band. She stated that on this floor residents rarely have DNR bands on". Additionally, Staff-3 indicated that, "There were 3 PMV containers in her drawer, but only 2 PMV's were found, (she) wondered if resident had one hidden which she could have put in herself".During the interview on 12/02/14 at 9:45 AM, Staff-1 stated that she noticed the PMV was not properly placed in the trach when the Resident-A was found unresponsive, and the drawer of the night stand where the PMV was stored was open and appeared sloppy which is not how she left it after she was done with the evening care. Staff-1 stated she remembered only seeing two PMV containers after she stored the valve.During an interview on 12/02/14 at 10:47 AM, Staff-4 went to Resident A-'s roommate on the evening of 11/15/14. Staff-4 described Resident-A as pale and he tried to wake her up. Staff-4 stated Resident-A was panting (short of breath). Staff-4 saw Staff-3 and told her to check the patient.During the interview on 12/02/14 at 9:30 AM, Administrator-1 stated that their internal investigation did not discover who could have placed the Passy-Muir Valve without deflating the trach cuff on Resident-A. Administrator-1 stated there was no nursing care plan and patient education regarding the Passy-Muir Valve and acknowledged there should have been a care plan. As a result, there was no documentation by the clinicians caring for Resident-A that demonstrated consistent and standardized care was delivered to ensure an otpimum level of care was given toward the care of a patient with a Passy-Muir Valve. The American Nurses Association (2015), a professional organization representing registered nurses and is involved in establishing standards of nursing practice, states, " Based on the assesment and diagnosis, the nurse sets measurable and achievable short and long range goals for the patient..., Assessment data, diagnosis, and goals are written in the patient's care plan so that nurses as well as other health professionals caring for the patient have access to it. Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient's record". Without a specific document delineating the plan of care, important issues may be neglected. During the same interview on 12/02/14 at 9:30 AM, Administrator-1 stated the policy and procedure for the Passy-Muir Speaking Valve was updated since the incident occured with Resident-A. Record review on 12/02/14 showed the updated policy revised 11/14 included the following new procedures: "B. Removing Passy-Muir Valve: 1. Clear both tracheal and oral secretions by having resident cough or by suctioning, if necessary, 2. Twist valve counterclockwise and remove, 3. Inflate cuff to prevent aspiration, 4. Wash valve, dry and store in Passy-Muir Valve container. Documentation: 1. The speaking valve will be care planned as method of communication, 2. Duration, frequency and tolerance of the Passy-Muir speaking valve when used by the resident will be documented on the resident's treatment sheet and electronic medical record with each appication and removal. Once resident is comfortable with use of Passy-Muir, use of Passy-Muir will be documented on treatment sheet with initials of licensure attending resident during the shift...".During an interview on 12/02/14 at 10:58 AM, Physician-1 stated that he instructed Resident-A regarding the PMV when she first got it but he wasn't sure if the staff performed education with Resident-A on her PMV. During an interview on 12/02/14 at 11:40 AM, Staff-5 stated there is no formal check-list for training with patients or family regarding Passy-Muir Valves. During the same interview, when asked if residents get education when they have a PMV, Staff-6 stated, " Usually the speech therapist initially educates the resident".The History and Physical Report by Physician-2 dated 11/15/14 indicated, "On the evening of (11/15/14), the circumstances surrounding the event are somewhat unclear, however, apparently, the patient had respiratory arrest on the ward secondary to complications of retract on trach without deflation of the cuff. The patient subsequently then developed a cardiac arrest asystole. The patient was resuscitated per ACLS protocol for approximately 25 minutes and subsequently, a sustainable pulsatile and circulating rhythm was returned..., Diagnostic Impression: ... 2. Primary respiratory arrest secondary to BiCAP placement without cuff deflation...". Record review on 12/02/14 showed Physician-3 dictated the following on 11/21/14: " The patient was apparently down for at least 20 to 25 minutes. She received a CPR as per ACLS protocol with her return of spontaneous circulation. She was subsequently transferred to the ICU, where she underwent hypothermic treatment for 24 hours. However, despite return of circulation and hypothermia treatment, she sustained significant hypoxic and brain damage and did not regain her prior cognitive function. After an extensive discussion with the family about her prognosis, decision was made to withdraw care and stop supportive treatment on the 20th. Subsequently, she was taken off the ventilator. All diagnostic lab draws and IV medications were stopped. She was put on morphine drip for pain and dyspnea...". Resident-A was transferred back to the original unit she came from.Record review on 12/02/14 showed Physician-1 dictated in his discharge summary dated 11/28/14 the following: "Diagnosis: Persistent Vegetative State ...Family had requested for the ventilator to be discontinued in the ICU and the patient survived. She was transferred (back to the unit she came from) for ongoing management. The family did not want any blood tests or any aggressive interventions performed. The patient was maintained comfortably. She expired on the afternoon of 11/28/2014. The cause of death is anoxic brain injury secondary to respiratory failure". During the interview on 12/02/14 at 10:58 AM, Physician-1 stated the coroner declined the case on 11/28/14 regarding Resident-A's death so an investigation as to the manner or cause of death or autopsy was not performed. The facility's policy and procedure titled, "Passy-Muir Speaking Valve", date revised 9/14, indicated the following: " ...Scope: Respiratory Care Practitioners, registered nurses and licenses vocational nurses..., Hazard/Complications/Precautions, 1. Do not use with inflated cuff...". On an interview on 12/02/14 at 9:45 AM, Administrator-1 stated the registered nurses, licensed vocational nurses and clinical nursing assistants were retrained about the facility policy and procedures regarding the Passy-Muir Valve. On an interview on 12/02/14 at 11:40 AM, Staff-7 stated the licensed practitioners on the unit Resident-A resided are required to do a one time, four hour respiratory orientation with a respiratory therapist that includes a checklist titled, "Passy-Muir Tracheostomy & Ventilator Speaking Valve Competency Checklist". This checklist has the clinician return demonstrate skills on how to "deflate cuff on tracheostomy tube slowly & completely...". An inflated trach cuff used together with the PMV would cause an airway obstruction and the patient would be unable to breathe. The Director of Staff Development provided documentation that every licensed staff on the unit successfully passed and completed this orientation and competency spanning from 5/30/1995 to 8/11/2014.According to the Passy-Muir Valve manufacturer's product description titled, "Passy-Muir Tracheostomy and Ventilator Speaking Valve Resource Guide" developed by Passy-Muir Inc. March 2003: "Contraindications for Use of the Passy-Muir Speaking Valve, A. Inflated Tracheostomy Tube Cuff: Controlling ventilation and gross aspiration are the two main issues that influence the decision to utilize a cuffed tracheostomy tube. If, for either of these reasons, the cuff cannot be deflated, then the PMV cannot be used as the cuff would cause an obstruction to exhaled air flow and the patient would be unable to exhale/breath..., If the patient has a cuffed tracheostomy tube, it is imperative that the cuff be fully deflated prior to PMV placement...". Record review showed the last tracheostomy tube change on Resident-A was on 10/31/14 at 5:04 PM. The tube was a Portex 8.0mm cuffed trach. Administrator-1 stated on a fax report dated 01/07/15 at 4:22 PM, Portex tubes are not fenestrated. With the PMV attached to the trach with a fully inflated cuff, Resident-A would have been unable to breathe.The hospital failed to follow their policy and procedure, and the manufacturer's recommendations for a Passy-Muir Valve that was left on a non-fenestrated trach with an inflated cuff on Resident-A. 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 and was a direct proximate cause of death of Resident A. |
| 220000416 |
Seton Medical Center |
220013024 |
B |
9-Mar-17 |
HVLZ11 |
6690 |
F206 483.15(e)(1)(2) POLICY TO PERMIT READMISSION BEYOND BED-HOLD
(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.
(i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident-
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services.
(ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.
(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in ? 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.
This REQUIREMENT is not met as evidenced by:
Based on interview and record review the facility failed to permit one Patient (Patient 1) to return to facility after Patient 1 was hospitalized on XXXXXXX 16.
This failure had the potential to result in significant decline in former social patterns preventing Patient 1 from maintaining or reaching his highest practicable level of well-being.
Findings:
Patient 1 was admitted to the facility on XXXXXXX16 with diagnosis that included hypertension (high blood pressure), dementia (a general term for a decline in mental ability severe enough to interfere with daily life), seizure disorder (abnormal movements or behavior due to unusual electrical activity in the brain), and aphasia (loss of ability to understand or express speech, caused by brain damage).
During a review of the clinical record for Patient 1, the minimum data set (MDS, a patient assessment tool) dated 10/26/16 set (MDS, a Patient assessment tool) indicated Patient 1 had moderately impaired daily decision-making skills. Patient 1 required set up and supervision for mobility and activities pf daily living.
The care plan (a written or computerized guide that organizes information about the patient's care) dated 6/24/16 with updates 6/25/16, 7/20/16, 10/3/16, 10/17/16, 12/24/16/ and 12/26/16 indicated interventions to address the behaviors of Patient 1 including; eating the meals of roommates, agitation related to changes in surrounding or routine and hitting and biting staff and other patients.
On 12/29/16, Patient 1 was observed hitting another patient and refused to stop hitting the other patient when directed. Patient 1 was placed on an involuntary psychiatric hold and transferred to an acute care facility for further evaluation.
On 1/3/17, Patient 1 was refused re-admission to the first available semi-private bed after being discharged from acute care facility.
During an interview with Director of Nursing (DON) on 1/19/17, at 3 PM, DON stated the "behaviors" of Patient 1 posed a danger to staff and other patients. When asked about the previous behaviors Admin stated Patient 1 has caused injuries to other patients and staff members. When asked how the facility handled these behaviors in the past Admin stated Patient 1 activities and location was being monitored every hour. Admin stated the facility does not have a locked unit making it difficult to monitor Patient 1.
DON stated the decision not to re-admit Patient 1 was a combined decision of Administrator (Admin), Medical Director (MD), and "senior management".
During an interview with Medical Director (MD) on 1/23/17, at 4 PM, MD stated there have been multiple incidents of Patient 1 abusing other patients and patients in the facility are afraid of Patient 1.
During an interview with Ombudsman on 1/19/17, at 8:45 AM, Ombudsman stated the "aggressive" behavior of Patient 1 increased after Patient 1 was moved to a new room. Ombudsman stated that in the two to three days before Patient 1 was transferred to acute care, he bit a care giver, tried to pull a patient out of bed, and caused another patient to sustain a broken wrist when he was pushed by Patient 1.
Review of acute hospital Psychiatric Evaluation Services notes indicated involuntary psychiatric hold discontinued on 1/1/17.
Review of acute hospital Hospitalist Progress notes dated 1/17/17 indicated Patient 1 sleeping during the day after receiving Seroquel (a drug used to treat bi-polar disorders), temazepam (a sedative), and lorazepam (a drug to relieve anxiety). Hospitalist Progress notes indicated skilled facility continued to deny re-admission of Patient 1.
The facility's policy and procedure titled "Bed Hold" dated 4/12 indicated ...when a patient is transferred for acute hospitalization ...the patient may be readmitted to the first available bed if the patient meets the admission criteria.
The facility's policy and procedure titled "Admission & Discharge Criteria - Subacute and Skilled Nursing dated 4/12 indicated ...Skilled Nursing a. Admission Criteria ...3. Medication being adjusted ...8. Alzheimer's or dementia...?
Review of clinical record of Patient 1 indicated a diagnosis of dementia.
Review of acute hospital notes indicated Patient 1 receiving the following medications Seroquel, temazepam, and lorazepam.
The facility's policy and procedure titled Admission & Discharge Criteria - Subacute and Skilled
Nursing dated 4/12 indicated ...Skilled Nursing ...Discharge Criteria 1. Patients will be discharged or transferred when one or more of the following criteria are met:
a. Minimum criteria for admission no longer met
b. Minimum criteria for admission no longer met
c. Acute changes in clinical status requiring a higher level of care
d. Patient elects to be transferred to an alternate facility and/or home, and has the appropriate resources and support systems to do so.
Therefore, the facility failed to permit one Patient (Patient 1) to return to the facility after Patient 1 was hospitalized on XXXXXXX16.
The violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients in the facility. |
| 230000144 |
Surprise Valley Community Hospital D/P SNF |
230009200 |
B |
05-Apr-12 |
4IVI11 |
4901 |
T22 DIV5 CH3 ART5-72527(a)(9) Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. The facility failed to protect Patient 1 from physical abuse by failing to prevent Patient 2 from hitting Patient 1 on the head with a rolled up newspaper on 10/20/11 and pulling her hair on 10/21/11. These incidents were unprovoked by Patient 1. This resulted in Patient 1 being abused twice by Patient 2.Patient 1 was readmitted to the facility on 3/21/11 with diagnoses that included stroke and dementia (a condition that caused a lack of mental function).The facility's minimum data set (MDS), an assessment tool, dated 8/7/11, described Patient 1 as having short and long term memory problems. Patient 1 was unable to walk without assistance and she needed assistance with all activities of daily living. Patient 2 was admitted to the facility 9/15/11 with diagnoses that included depression and Alzheimer's dementia. The facility's admission MDS, dated 9/28/11, described Patient 2 as having short and long term memory loss, trouble concentrating, rejecting care, wandering and had physical behavior, striking out directed at patients and multiple incidents directed at staff. On 10/26/11 at 9:20 am, in an observation and interview of Patient 1, she did not respond or make eye contact.On 10/18/11 at 2 pm, the nurses notes contained two other documented incidents where Patient 2 physically abused two residents by hitting one resident on the arm and the other on the back.The nurses notes indicated that on 10/20/11 at 1:10 pm after lunch, Patient 1 was sitting at the dining room table in her wheelchair. Patient 2 was standing directly behind Patient 1 with a rolled up newspaper in his hand. In a written statement, dated 10/20/11, Certified Nurses Aide (CNA) A didn't see Patient 2 hit Patient 1, but did hear Patient 1 say "ouch" and he saw her put her hand up to the side of her face.In a nurses note on 10/21/11 at 1:15 pm after lunch, indicated that Patient 1 was sitting at the dining room table in her wheelchair playing a game of punch ball with two of the activities staff. Patient 2 walked up to the game and was standing behind Patient 1. He reached out and pulled her hair pulling her head back and forth, and she yelled out.A care plan, dated 10/21/11, titled, "Disturbed Thought Process," indicated that Patient 2 was to be assessed by nursing staff for any anger, agitation, anxiety or possible combativeness." Approaches included: 1. Remove Resident from confrontational environment immediately and implement safety measures as necessary. A care plan, dated 10/24/11, titled, "Aggravation and physical abuse when patient is exposed to much stimuli," Approaches included: 1. Providing calm environment 2. Having patient stay out of a high stimuli environment.The care plans were not updated to include additional interventions specific to Patient 2's known behaviors of physical abuse after four incidents with 3 different patients in four days.The facility failed to develop comprehensive individualized care plans that included interventions to prevent further abuse to patients by Patient 2. The facility failed to have a care plan specific to Patient 2's care needs, related to known behaviors of striking out and abusing other patients, in order to prevent further abuse. In an interview with the Director of Nurses on 3/15/12 at 2:30 pm, she stated that they had provided sitters for Patient 2 when he had behavior problems, however, this was not included in the care plans. She was not able to find a record for 10/20/11 or 10/21/11 that Patient 2 had a sitter assigned to him. She was not able to show that they had updated their care plans after each incident of abuse by Patient 2 towards other patients, in order to prevent further abuse from occurring.On 10/20/11, the facilities undated policy and procedure titled, "Elder Abuse," was reviewed. On page 2 under Prevention Procedure, #4 indicated that "The nursing staff will monitor, assess and care plan residents with needs and behaviors which might lead to conflict or neglect."Therefore, the facility failed to protect Patient 1 from physical abuse by Patient 2. On two separate occasions Patient 2 was allowed to be close enough to Patient 1 to hit her on the head with a rolled up newspaper and pull her hair, pulling her head back and forth.The violation of this regulation had a direct or immediate relationship to Patient 1's safety, security, and right to be free from physical abuse. |
| 230000043 |
Shasta View Estates |
230009590 |
B |
29-Apr-13 |
JB9P11 |
3272 |
F 225 483.13(c)(1)(ii)-(iii), (c)(2) - (4) INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The facility failed to report a witnessed physical altercation between Patient 1 and Patient 2 to the state survey agency, the California Department of Public Health (CDPH), Licensing and Certification, within 24 hours, as required by Federal and State regulations, and the facility's abuse policy. This failure had the potential for patients' safety to be at risk. On 10/29/12 at 2:21 pm, the CDPH received a faxed notification, from the facility, that Patient 1 was involved in two patient to patient altercations; one on 10/26/12 at 7:05 pm, and a second on 10/28/12 at 5 pm.The facility's "Abuse Protocols - Administrative Protocol" revised 9/03, read, "Reporting: 1. An initial written report is completed and the CDPH, Licensing and Certification, is notified within twenty-four (24) hours. Patient 1 and Patient 2's records were reviewed on 11/1/12. Patient 1's record contained a nurse's notes, dated 10/26/12 (no time), that read, "Nurse noticed Patient 1 hitting Patient 2 closed fist to arm outside of Patient 2's room."Patient 2's record contained a corresponding nurse's notes, dated 10/26/12 at 10 pm, that read, "A licensed nurse saw Patient 2 back her wheelchair up against Patient 1 who was sitting in his wheelchair in the hallway. Patient 1's right hand came into contact with Patient 2's left arm several times."Both nurse's notes contained a statement that the facility's Assistant Director of Nurses and Administrator were informed of the incident. On 11/1/12 at 3:45 pm, the facility Administrator stated that the facility had not followed their policy to inform the CDPH within 24 hours, when the incident that occurred between Patient 1 and Patient 2 on 10/26/12 at 7:05 pm, was not reported until 10/29/12 at 2:21 pm, 67 hours or two and a half days later. |
| 230000144 |
Surprise Valley Community Hospital D/P SNF |
230010002 |
B |
09-Jul-13 |
CI2111 |
6507 |
F 223 483.13(b), 483.13(c)(1)(i) FREE FROM ABUSE/INVOLUNTARY SECLUSION The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The facility failed to protect Patient 1 from physical abuse by Patient 2 and ensure implementation of both their Elder Abuse policy and procedure and Patient 2's behavioral disturbances care plan. These failures, as well as failing to supervise patients while in the dining room, resulted in one of two sampled patients (Patient 1) experiencing abuse and mistreatment by Patient 2, and had the potential for other patients to be abused and sustain avoidable injuries.The facility's "Elder Abuse" policy and procedure, revised 8/06, described the following procedure: " Nursing management will use all means necessary ... to meet the needs of the patients. The nursing staff will monitor, assess and care plan patients with needs and behaviors which might lead to conflict or neglect." On 8/27/12, Patient 1 and 2's record was reviewed.Patient 1 was admitted on 3/21/11 with diagnoses that included dementia and depression. The Minimum Data Sets (MDS), an assessment tool, dated 8/2/12, reflected that Patient 1 had cognitive impairments and episodes of paranoia. Patient 1's care plan for Mood/Behavioral symptoms that was developed on 7/22/08 and reviewed on 5/3/12, read, "Patient exhibits symptoms of paranoia at times due to delusions. She has persistent anger towards others daily. Patient can be verbally and physically abusive to others." The facility's goal was "Environment will be safe for Patient 1 and other patients." On 8/28/12 at 11:20 am, Patient 1 was interviewed. She was able to communicate basic information, then became confused. Twenty minutes later, at 11:45 am, Patient 1 was in the dining room, wearing a clothing protector, seated at a table with other patients.Patient 2 was admitted to the facility on 9/15/11, with diagnosis that included late stage Alzheimer's. The MDS, dated 6/28/12, indicated that Patient 2 was able to ambulate freely throughout the facility with the use of a merri-walker (a enclosed walker with a seat). Patient 2 also had severe cognitive impairment with behavioral issues. Patient 2's Behavioral disturbances care plan, developed on 9/19/11 and reviewed on 6/28/12, read, "... physical abuse secondary to disturbed thought process...Patient can become aggressive and combative toward other patients and staff without provocation." The facility goals were that Patient 2 would not have daily episodes of agitation/combativeness, and no injuries to resident or staff daily. One of the interventions/approaches to accomplish this goal was for "Staff to observe/monitor patient closely for any anger, agitation, and anxiety or possible combativeness and remove patient from any confrontational and/or moderate-high stimulating environment immediately..."Patient 2's care plan entry, (number 15) dated 5/25/12, read, "This patient hit another patient (Patient 1) on the back of the head with a open hand while being wheeled to the common area for dinner. There were no injuries to the other patient. He was not agitated at the time." The care plan goals read, "1. Patient (2) will not cause any injuries to himself or any patients daily. 2. Patient (2) will be safely removed from areas whenever he becomes agitated/aggressive daily. 3. Patient (2) will be assisted to and from dining room to avoid being to close to other patients daily." On 7/27/12 at 4:20 pm, Patient 2 was observed in his merri-walker ambulating in hallways and entering the dining room where other patients were present. An interview was attempted, however, Patient 2 was confused and was unable to respond to conversation and questions.On 8/27/12 at 1:30 pm, Certified Nurses Aide (CNA) B was interviewed. CNA B stated that on 7/19/12 at about 5:40 pm, she was standing in the hall, outside the dining room, when she heard loud yelling coming from the dining room. When she entered the dining room to see what was going on, she saw Patient 2 standing behind Patient 1, pulling on the back of Patient 1's clothing protector (a bib that attaches around the neck). Patient 1 was pulling on the front of clothing protector, yelling, " ...get that SOB away from me." CNA B stated that Patient 1 was very upset, and was pulling forward on the clothing protector to pull it away from her neck to keep from choking. CNA B stated that she had to release Patient 2's hands, that were gripping and pulling the clothes protector the from the back, to stop the incident.CNA B stated, at the time of the incident there were six patients, including Patients 1 and 2, and no staff present in the dining room. CNA B explained that Patient 2 sits at a different dining room table than Patient 1, and that the incident occurred as Patient 2 was passing by Patient 1's table he grabbed the back of her clothing protector. Patient 2 was supposed to be accompanied by staff "...to avoid being too close to other patients...", in accordance with his care plan.On 8/28/12 at 1 pm, Registered Nurse (RN) A stated that she assessed Patient 1 after the incident. Patient 1's neck was reddened with a red line on the front of her neck, from the clothing protector being pulled from the back. RN A stated that Patient 2 would have sudden outbursts of aggression towards patients and staff, and confirmed that staff was not in the dining room at the time of the incident on 7/19/12. On 8/28/12 at 10:30 am, the Director of Nurses (DON) was interviewed. The DON confirmed that Patient 2's care plan instructed to have staff present with Patient 2 while in the dining room. The DON stated that Patient 2 had entered the dining room and grabbed Patient 1's clothing protector when staff were not supervising his whereabouts.The facility failed to protect Patient 1 from physical abuse by Patient 2 and ensure implementation of both their Elder Abuse policy and procedure and Patient 2's behavioral disturbances care plan. These failures, as well as failing to supervise patients while in the dining room, resulted in one of two sampled patients (Patient 1) experiencing abuse and mistreatment by Patient 2, and had the potential for other patients to be abused and sustain avoidable injuries.These violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 230000144 |
Surprise Valley Community Hospital D/P SNF |
230012762 |
B |
13-Feb-17 |
P9HN11 |
11523 |
F 155 483.109(b)(4) RIGHT TO REFUSE; FORMULATE ADVANCE DIRECTIVES
The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph (8) of this section.
The facility must comply with the requirements specified in subpart I of part 489 of this chapter related to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law.
The facility failed to ensure that a patient's right to refuse treatment was upheld (Patient 1), when staff were bathing and providing incontinence hygiene care and administered an influenza (flu) immunization injection, against Patient 1's wishes.
This denied Patient 1's right to refuse treatment, which resulted in increased levels of agitation, causing him to strike out at staff, attempt to spit on staff and bite staff. Staff proceeded to then place their hands over his arms, restraining his hands on his chest, and applying a face visor (a staff personal protective item) or a face mask to prevent being bitten or spit upon.
Patient 1's record was reviewed. Patient 1 was a 69 year old male. Patient 1 was admitted to the facility on XXXXXXX16 with diagnoses that included quadriplegia (paralysis involving all four limbs, though Patient 1 had partial use of his upper extremities), chronic pain, anxiety, depression, and post traumatic stress disorder (PTSD). Patient 1's Social Service Assessment, dated 3/21/16, read Patient 1 was responsible for self. A nurse practitioner note written 3/23/16 read "Spoke with Public Guardian regarding conservatorship, public guardian states she is for financial only. Resident can sign his own consents and make his own decisions per public guardian."
Patient 1's conservatorship papers in the record, filed 8/23/13, were noted incomplete, the court findings read "Probate Conservator of the person and estate... that (Patient 1) is unable to properly provide for his or her personal needs for physical help, food, clothing, shelter..." On page three of the orders the court granted conservatorship over estate only.
In an interview on 11/9/16 at 2:50 pm, Patient 1's public guardian acknowledged that the court orders were confusing and incorrectly prepared. She stated that she thought the court had granted power over his estate and medical decisions. The public guardian stated she had given a verbal authorization for a flu shot to be given to Patient 1, which was administered on 11/4/16. She stated that at no time did she consent to medical care and treatment that required a "hands on" approach against Patient 1's wishes. She stated that she would have had to consult with a county attorney to consider removing his right to refuse treatment.
A nurse's note in Patient 1's record dated 11/4/16 at 3:45 pm, contained documentation that the flu vaccine was given on 11/4/16.
The month of 10/2016 Patient 1's Activities of Daily Living (ADL) record had multiple documented (almost daily) refusals for incontinence care, showers, soiled bed changes. The record contained documentation that Patient 1 was verbally, and physically abusive to staff and his physician.
In an interview on 9/29/16 at 11:15 am, Patient 1's physician (Medical Doctor MD) A stated that Patient 1 had attempted to bite him during care. "He is attempting to be as bad and dirty as possible." MD A stated that Patient 1's refusals have been worse in the last few months.
On 9/29/16 at 11:45 am, Patient 1 was observed in his room, had his door closed, answered to the knock on door, and agreed to be interviewed. Patient 1 had his light off, and drapes closed. Urine odor was apparent. In a concurrent interview, Patient 1 complained about his assigned public guardian not sending him clothes that fit. He complained that both of his doctors did not believe in using narcotic (strong medication for pain) medication. He stated his pain starts at the top of his head to tip of his toe. He rated his pain at 8 out of 10. During the interview, Patient 1's assigned Certified Nursing Assistant (CNA) B was observed coming in to the room. He allowed her to empty his urinal, kept between his legs, but not to do a bed change. He told her he would shower later after lunch, and the bed change could occur at that time.
On 10/5/16 at 5:15 pm, the facility staff were observed rewarding Patient 1 with compliance with showers and bed changes by giving him a beer.
During review of Patient 1's record, this program was not specifically documented in the care plan and no physician's order was obtained for the beer.
Patient 1's record contained the following Care Plans, updated 9/27/16, which included the following:
1. Alteration in Activities-Self Concept Disturbance with approaches that included encourage activities and to verbalize feelings;
2. Urinary Incontinence with approach to maintain environment free of skin irritants;
3. Alteration in ADL function: bathing hygiene with approaches that included active/passive range of motion as tolerated and allow for expression of loss and verbalization of feelings.
4. Psychosocial Well Being: self esteem disturbance with approaches that included allow time to answer questions.
5. Potential for alteration in mood related to refusing ADL care daily with approaches that included 1:1 with social services and include resident in care planning sessions.
6. Impaired Mobility that included approach to turn every two hours.
7. Pain: shoulder neck and leg pain with pain medication as only approach.
10. Potential for alteration in skin integrity related to three reddened areas on back, due to refusals to be changed and cleaned regularly after voiding and BM's. Has poured his urinal on his bed with interventions that include validate his cooperation with care and validate his cooperation with rewards.
11. Psychotropic Drug Use: Takes Ativan for anxiety with intervention that includes one on one conversations whenever possible regarding fears, anger issues, and anxieties.
12. Behavior anxiety/PTSD, depression, anger with intervention that included praise his good choices.
13. Non -compliance: related to refusing to get out of bed, refusing to be turned frequently, anger issues with approaches "1. Explain to resident in gentle way the reason for turning frequently and getting out of bed, and 2. approach resident calmly and non threatening manner for care due to PTSD and anger issues."
In an interview on 10/6/15 at 9:45 am, DON acknowledged that Patient 1's care plan interventions had been ineffective thus far, in ensuring he complied with care.
On 10/31/16 at 2 pm, a nursing note by the DON, read "Was called into residents room by CNAs. The CNAs were attempting to change the linen and clean the resident. The resident is resistant to care. The odor emitting from his room is so strong with an acidic odor that your eyes water. The resident began spitting on staff, threw Pepsi on staff, and attempted to throw urine. The DON held the residents hands and he was given a bed bath and linen change..."
On 11/8/16 at 11 am, Patient 1 was observed in his room without a roommate, window shades open, and was watching television and looking outside. His room was much brighter than when last observed on 9/29/16. A strong urine odor was present. In a concurrent interview, Patient 1 stated "I want to be out of here more than ever". He stated he was held down by nurses for them to "wipe his butt", clean urine, and change his chucks (disposable under pad). He stated "they cannot do that". Patient 1 stated "It's up to me if anyone does anything." He stated that he had agreed to care with one staff, and the next thing that happened was a group of four staff came in. He stated these staff disregarded his refusals, holding his head down and doing his care and bed change. Patient 1 also stated that he refused a flu shot and it was given without his consent. He was told that his conservator had agreed, and he was given the injection.
In an interview on 11/9/16 at 10:30 am, Assistant DON stated that she had been in Patient 1's room and giving hygiene care despite his refusals. Patient 1 had been refusing incontinence care all morning. She stated his bed was soaked with urine and feces, at about 1 pm (unknown date) and she explained "it was necessary that he be cleaned up." Assistant DON stated that Patient 1 stated he did not care, in response to her encouragement. "I like certain people and they are the only ones I will allow to care for me." Assistant DON stated that the conservator had authorized "hands on care". Assistant DON further stated MD A and DON had stated "We have to take care of him no matter what."
In an interview on 11/9/16 at 10:45 am, DON stated "You provide the solution. There are no effective interventions. I am not sure when I made the decision to hold his hands as he was cleaned. His head was moved to put on a plastic face shield." DON stated that she trained other staff on this intervention. DON acknowledged Patient 1's statement made on 11/8/16 at 11 am, that an approach with four staff members holding him down was done, and that Patient 1 was spouting out profanities and threats. She stated that staff had to hold his hands to his chest to protect themselves.
In an interview on 11/9/16 at 1:20 pm, MD A stated, related to Patient 1, "I think he should be getting the hell out of here, we can't ignore him." "I am proud of what we did."
In an interview on 11/9/16 at 1:15 pm, Licensed Nurse (LN) B stated if Patient 1 refused care that "sometimes you just have to do it".
The facility policy titled "Resident Rights" was reviewed. The policy directed that residents are entitled to exercise their rights and privileges to the fullest extent possible. It also directed that the facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity.
In an interview on 11/10/16 at 8:30 am, CNA C stated that she was involved with a bed bath where Patient 1's hands were held. "We explained that he needed to be changed. He said yes then tried to kick us". CNA C stated that another Nursing Assistant (NA) D and the Assistant DON were present during this instance of holding him down to provide care.
In an interview on 11/10/16 at 8:40 am, NA D stated that she was involved with a four person staff altercation with Patient 1 when he kept refusing care. "He was mad because we were going to change him. The Assistant DON instructed us to hold his arms and hands. We switched places to do the care. A mask was used due to spitting. I did not agree with that".
A review of Patient 1's record showed that the interventions to proceed with care by holding him down despite his refusals was not documented in his multiple care plans.
The facility failed to ensure that Patient 1's right to refuse treatment was upheld, when staff were bathing and providing incontinence hygiene care and administered an influenza (flu) immunization injection, against Patient 1's wishes. This failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 230000144 |
Surprise Valley Community Hospital D/P SNF |
230012763 |
B |
13-Feb-17 |
P9HN11 |
6299 |
F309 483.25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
The facility failed to provide the necessary care and services to one patient (Patient 2) when licensed facility staff did not provide Cardio Pulmonary Resuscitation (CPR, an emergency lifesaving procedure that is done when someone's breathing or heartbeat stops). This failure resulted in life sustaining interventions not being taken to save her life, when she stopped breathing, and her heart stopped, in the presence of the licensed nurse, and she passed away.
Patient 2's record was reviewed. Patient 2 was a 69 year old female. Patient 2 was admitted to the facility on 6/6/05 with diagnosis that included blindness, diabetes, chronic pain, nicotine dependence, and Chronic Obstructive Pulmonary Disease (COPD- a condition that narrows the residents airway, resulting in air hunger or shortness of breath).
A "Physician Attestation," signed 10/28/16, listed the immediate cause of death was Cardio Pulmonary Arrest (heart and lungs stop working). Patient 2 had a "Physician Orders for Life-Sustaining Treatment (POLST)," signed on 4/2/15 by Patient 2, and her physician. The POLST identified that she desired to have "Attempted Resuscitation/CPR."
A Charge Registered Nurse (CRN) wrote in Patient 2's "Nurse's Notes" that on 10/27/16, at approximately 6 am, he was called to Patient 2's room to assist another staff , Licensed Vocational Nurse (LN) A, to position her up in her bed, so her oxygen could be applied. Patient 2 was upset and stated that she wanted to go outside and smoke a cigarette, even though she had just received a treatment for her complaint of difficult breathing. CRN wrote that after raising the head of Patient 2's bed up and applying oxygen that she suddenly stopped breathing, and slumped down in her bed. CRN documented that he checked for breathing and pulse and verified that she was not breathing and had no pulse. CRN wrote "Pt (patient) was on a soft spring mattress without back support so it was not possible to do chest compressions." CRN's note read that Patient 2's physician (MD) called her death at 6:04 am 10/27/16.
A facility "Code Blue (an emergency situation announced in a facility in which a patient is in cardiopulmonary arrest, requiring a team of providers (sometimes called a 'code team') to rush to the specific location and begin immediate resuscitative effort) Policy: Hospital," dated 8/2012, read that the first person on scene calls the code so staff can respond, then begins CPR, the North Station Nurse gets the crash cart (cart with emergency life saving supplies and medications) to the location immediately.
In an interview on 11/8/16 at 7 pm, LN A stated she had been working with Patient 2 much of the evening on 10/26/16. LN A further stated that at about 5:30 am on 10/27/16 Patient 2 was given a breathing treatment, then was taken outside, where Patient 2 stated that the fresh air felt good and that she wanted a cigarette. LN A explained to Patient 2 that her difficulties with breathing would make smoking impossible, and that the doctor had been called and wanted her on oxygen. LN A stated that she then took Patient 2 to her room. Patient 2 had slumped back in her bed but was still breathing. She asked CRN to help her as Patient 2 was difficult to position. CRN asked LN A to call the physician and she was asked to get a mask for Patient 2's oxygen. LN A stated that when she returned to the room Patient 2 was not breathing. LN A stated that she did not know Patient 2's code status (what type of intervention a health care team will conduct should a patient's heart stop beating or lungs stop moving air in the event of a medical emergency).
In an interview on 11/8/16 at 7:30 pm, CRN stated that the emergency crash cart (with a back board, and ambu-bag for ventilation, and oxygen) was not obtained for Patient 2 and no code blue was announced for Patient 2, though the doctor was called to come in. CRN stated he was not aware of Patient 2's code status. CRN stated he made a judgement call that any resuscitation would be futile (of no use). CRN stated that he had back problems that prevented him from lowering Patient 2 to the floor. CRN also stated that his Advanced Cardiac Life Support (ACLS) Training (which included his CPR certification) had just expired a few days ago, on 11/4/16.
In an interview on 11/9/16 at 10:15, Interim Human Resources Staff (IHRS) stated that there was not a system to ensure that CPR, ACLS, Pediatric Advanced Life Support (PALS) was being tracked to ensure that staff had current training. IHRS stated that she had discovered this upon taking over the interim position.
A facility provided job description for "Registered Nurse," dated 2/5/02, read "Essential Duties and Responsibilities include the following... ACLS certification is required... Is responsible as Charge Nurse for Acute, including ER, and SNF... Will initiate all emergency treatments and protocol according to Surprise Valley Hospital policy..."
In an interview on 11/9/16 at 12 pm, DON stated that she was aware of the problem with CRN not performing CPR (coding her) when she came in to work on 10/27/06, the morning of Patient 2's death. DON stated that she had not completed an unusual occurrence report, but had done her own unwritten investigation. DON stated that she educated staff on the crash cart and discovered that the wheels on the cart were frozen in place and could not be moved. DON stated that Patient 2 should have been transferred to the emergency room or that she should have been placed on the floor to do CPR.
The facility failed to provide the necessary care and services to Patient 2 when licensed facility staff did not provide Cardio Pulmonary Resuscitation. This failure resulted in life sustaining interventions not being taken to save her life, when she stopped breathing, and her heart stopped, in the presence of the licensed nurse, and she passed away. This failure had a direct or immediate relationship to the health, safety or security of patients. |
| 240000099 |
Sierra Vista |
240009177 |
B |
23-Mar-12 |
4ICJ11 |
7787 |
REGULATION VIOLATION: Title 22 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.The facility failed to promptly notify the physician when Patient 1 refused to take his medication for two days, which resulted in Patient 1 to experience increased agitation and resulted in a physical altercation.An unannounced visit was made to the facility on February 28, 2011 at 8:30 AM to investigate an entity reported event.A review of Patient 1's record conducted on February 28, 2011, revealed that Patient 1 was a 28 year old male, admitted to the facility on March 23, 2010 with diagnoses of schizophrenia (a mental disorder characterized by disordered thought process and emotional responses) and somatoform disorder (a mental disorder characterized by unexplainable physical symptoms that suggest a medical disorder).A review of the Minimum Data Set (a standardized assessment tool) dated September 23, 2010, revealed that Patient 1 was partially independent with decision making and had persistent anger that was easily altered. A review of the facility's "Incident Report" dated November 4, 2010, indicated that at 2:30 AM staff responded to banging in Patient 2's room. The documentation showed that Patient 1 had Patient 2's head locked in his arms and was repeatedly hitting him with a closed fist in the face. Patient 1 then proceeded to grab Patient 2 by the hair and repeatedly slam him into the bed frame. Further review of the documentation showed that continuous calls for redirection occurred which were ineffective. Patient 1 was "locked onto peer with flailing fists and extreme aggression," which prevented initial staff members from apprehending Patient 1. Patient 1 slammed Patient 2's head onto the floor three times, then got up, backed away from peer and sat on his bed in a "calm and quiet" manner.A review of Patient 2's record conducted on February 28, 2011, revealed that Patient 2 was a 24 year old male, admitted to the facility on February 5, 2010 with diagnoses of paranoid schizophrenia (a disordered thought process and emotional responses characterized by auditory or visual hallucinations).A review of the MDS dated August 14, 2010, revealed that Patient 2 was partially independent with daily decision making. He had persistent anger, unrealistic fears, and repetitive physical movements, which were all easily altered.Further review of the "Incident Report" showed that Patient 2's assessment showed "large amounts of red fluid and immediate swelling to nose/cheek." There was a bump to the back of his head 3 cm (centimeters) by 3 cm with red discoloration and purple discoloration to the bridge of his nose. Patient 2 was sent to the emergency room for evaluation and returned to the facility November 4, 2010 with a diagnosis of a nasal bridge fracture. Physician's orders included Ibuprofen (an anti-inflammatory medication used for pain management) 600 mg PO as needed every 6 hours with food and to elevate the head of the bed when laying down to aid breathing.A review of Patient 1's medication administration record (MAR) dated November 2010, revealed that Patient 1 refused his routine medications on November 2, 2010 and November 3, 2010. These medications included Chlorpromazine HCl 300 mg (milligrams) PO (by mouth) daily, Abilify 15 mg PO twice a day (drugs used to control psychotic episodes), Klonopin 1 mg PO twice a day (a medication used to control anxiety in schizophrenic patients), Lithium Citrate 300 mg PO once a day (a medication used to control bipolar behavior) and Vistaril 25 mg PO twice a day (an anti-anxiety medication).A review of the documentation titled "Side Effects Episode Record" dated November 2010, included documentation dated November 2, 2010 at 9 PM, that showed Patient 1, "refused all q HS meds (before bed medications) ...RN supervisor notified." However, there was no documentation that the physician was notified that Patient 1 refused his medications.A review of the documentation titled "Behavior Episode Record for Bipolar Related Behavior" dated November 2010, showed checkmarks next to "persistent depressed mood" and "persistent agitation, restlessness, and irritability". Review of the documentation showed that Patient 1 had two episodes of behavior on November 3, 2010 during the evening shift.A review of the documentation titled "Behavior Episode Record for Anxiety Related Disorders" dated November 2010, showed a checkmark next to "recurrent anger outbursts" and listed two occurrences on November 3, 2010 during the day shift and one during the evening shift.A review of the documentation titled "Behavior Episode Record for Psychosis Related Disorders" dated November 2010, showed checkmarks next to "danger to others" and "persistent audio hallucinations," which revealed 3 episodes on November 4, 2010 during the night shift.A review of Patient 1's medication administration record showed that Patient 1 received a PRN (as needed) dose of Chlorpromazine 100 mg PO (an antipsychotic medication) for "increased agitation" on November 3, 2010 at 4:15 PM. The "PRN Sheet" listed medication as "effective" at 3 PM. There was no documentation to show that the physician was notified.A review of the "PRN Psychotropic Medication Pre-administration Flow Sheet" dated November 3, 2010, revealed that Patient 1 showed, "increased agitation as evidenced by crying, yelling and being verbally aggressive towards others" and that alternative interventions were not effective. However, there was no documentation to show that the physician was notified of the ineffective interventions to decrease Patient 1's agitation.Further review of the medication administration record revealed that Patient 1 received another dose of Chlorpromazine at 2 AM on November 4, 2010 for increased agitation, which was noted as "ineffective" at 4:30 AM.Review of the "PRN Psychotropic Medication Pre-administration Flow Sheet" revealed that Patient 1 showed, "increased agitation (by) pacing on the hallway and being unable to follow redirection, stating I am mad right now." Documented alternate interventions were not effective. There was no documentation to show that the physician was notified of the ineffective interventions attempted to decrease Patient 1's agitation.During an interview with the Administrator on February 28, 2011 at 12:45 PM, the Administrator stated that the policy and procedure stipulated that licensed staff should notify the physician when a patient refuses care and services. She confirmed that there was no documentation that the physician was notified regarding Patient 1's refusal of medication, escalation of behavior or change in overall condition.A review of the facility's policy and procedure titled "Care and Services" dated January, 2008, included the following, "The licensed nurse notifies the physician of the resident's refusal of treatment." The policy further stipulated that, "The Licensed nurse or designee documents and notifies the resident's physician and responsible party of: change in condition, including progress and/or decline in physical or mental function and resident refusal of care or services."The facility failed to notify the physician that Patient 1 refused to take his medications for two days. The facility failed to notify the physician of Patient 1's escalation in behavior episodes. In addition, the facility failed to notify the physician that alternative interventions to medication were not effective.These facility failures had a direct or immediate relationship to the health, safety or security of long-term health care patients or residents. |
| 240000060 |
Spring Valley Post Acute LLC |
240009228 |
B |
19-Apr-12 |
NC6U11 |
8685 |
REGULATION VIOLATION: Title 22 72311 Nursing Service - General and 72301 Required Services 72311 (a) Nursing service shall include, but not be limited to, th following: (2) Implementing of each patient?s plan of care according to the methods indicated. Each patient?s care shall be based on this plan. AND 72301 (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated.The facility failed to implement the plan of care by failing to ensure Patient A?s side rails were consistently in the up position when the patient was in bed.The facility failed to ensure that the physician?s order was implemented when Patient A?s side rail was not kept up as ordered when in bed. On June 8, 2010, Patient A?s side rails were left down and the patient fell out of bed. X-rays taken on June 10, 2010 at the patient scheduled Orthopedic (specialty concerned with deformities, injuries, and diseases of the bones, joints, ligaments, tendons, and muscles) appointment showed displacement (separation of bones in a joint from their normal position) of the right femur (the long bone in the leg) fracture (break) requiring surgical interventions.A review of the acute care hospital notes dated June 11, 2010 at 2:00 AM indicated that Patient A was admitted to the skilled care facility about one week ago. The patient fell out of bed 3 days ago at the skilled nursing facility and re-fractured the right femur (leg bone). The patient was transferred from the local hospital to a second acute care hospital for a higher level of care. On March 3, 2011, Patient A?s medical record was reviewed. Patient A was admitted to the facility on June 3, 2010 from the acute care hospital after an open reduction and internal fixation (O.R.I.F is a method of surgically repairing a fractured bone. This included the use of plates and screws or an intramedullary (IM) rod to stabilize the bone) of the right distal (far distance from the hip) femur on May 24, 2010 for fractures sustained in a fall at home on May 21, 2010. Other diagnoses included an infection of the bladder, diabetes mellitus (elevated blood glucose) and cerebral vascular accident (CVA occurs when there is a blockage in blood supply to the brain) with right sided weakness.The ?Nurse?s Admission Record? dated June 3, 2010 indicated that Patient A was ?oriented to functions of the call light; was some-what confused but was able to make needs known?. The ?Interdisciplinary Team (IDT) Physical /Chemical Restraint Assessment & Consent? form dated on June 3, 2010 by nursing, included the following: ?1. Reason for the bed rails: a. Resident request. b. Family request. c. Safety measure as determine by the IDT. d. Restraint as determined by the IDT. 2. Diagnosis pertaining to mobility: ORIF right hip 3. Ambulation and transfer ability: maximum assist. 4. Mental status: Altered level of consciousness (ALOC) 5. Continence: Incontinent of bladder and bowel. 6. History of falls: yes. 7. Psychoactive or sleeping medications and reasons: blank 8. Current restraint order and date: side rails up while in bed. 9. Resident?s reaction to bedrails:a. Resident is not able to lower side rails. b. Resident is not able to unlock and remove safety device. 10. Less restrictive methods attempted: monitor every shift and as needed. 11. Team recommendations: side rails up when in bed. 12. If restraints are recommended, approaches to prevent decreased functioning: release and repositioned every 2 hours and as needed?. A review of the physician admission orders dated June 3, 2010, included the following: a. Side rails. b. Therapy evaluation and treatment: physical, occupational and speech. Review of the care plan titled, ?At risk for falls due to history of falls and decreased mobility?, dated June 4, 2010 included the following: ?Side rails up while in bed and call light within reach and answer light promptly.? A review of the Medication Administration Record (MAR) dated 6/3/10, included, ?Side rails up x 2 while in bed for safety?. Review of the nurses notes dated June 8, 2010 at 9:30 AM indicated that Certified Nursing Assistant (CNA) 1 found Patient A lying on the floor by the bed. The patient was face down over the base of the bedside table. The left bed side rail was down due to the breakfast meal tray situated in front of the patient. Patient A stated that she pushed back to the side and accidentally fell out of bed. Patient A complained of ?pain all over.? Right hip and bilateral rib X-rays were ordered. The facility failed to implement the plan of care and the physician orders that stipulated the side rails were to remain in the up position when the patient was in bed. A review of the mobile X-rays completed on June 8, 2010 showed a right hip arthroplasty (surgery to relieve pain and restore range of motion by realigning or reconstructing a joint) intact with a stable proximal (bone closest to the hip) femur fracture. Review of the IDT notes dated June 10, 2010 indicated ?[Patient A] on June 8, 2010, while eating a meal in bed pushed her side table away with her non-affected left side and proceeded to fall from bed.? X-rays completed on June 8, 2010 in the facility revealed no new findings. However, Patient A went to a previously scheduled orthopedic appointment on June 10, 2010 and did not return to the facility.On March 3, 2011, at approximately 11:00 AM, a telephone interview was conducted with the Director of Nursing (DON). Policies and procedures were requested. The DON stated that CNA 1, who was assigned to Patient A at the time of the fall, was no longer employed at the facility; the nurse supervisor who responded to the incident only worked on call. The DON stated that she was not employed at the facility at the time and was not familiar with the incident.On March 3, 2011, a review was conducted of the ?Adult progress soap note? dated June 10, 2010, completed on the visit to the orthopedic office. The reported indicated, ?Fell out of bed 3 days ago; X-rays done, diagnosis re-fracture of femur?. A review of the right femur x-rays completed on June 10, 2010, at the acute care hospital during Patient A?s routine post operative orthopedic follow-up visit, included the following: ?Acute comminuted fracture (a bone is broken, splintered or crushed into a number of pieces) involving the proximal (bone closest to the hip) and mid-portion (bone in the middle of the thigh) of the femur.? ?There is 3-4 centimeters (cm) of medial and posterior displacement of the distal femur.? ?There is 4 cm displacement of a fracture fragment involving the mid femur.? ?The patient had a prior ORIF of the right distal femur with IM rod and screws.? ?The patient had a right total hip replacement.? Review of the physician summary report dated June 10, 2010, showed a diagnosis of right femur spiral fracture and anatomical displacement of right hip prosthesis. Patient A was transferred to another acute care facility for a higher level of care. On May 25, 2011, at approximately 11:35 AM, an interview was conducted with the Registered Nurse (RN) 1 supervisor who was responsible for Patient A at the time of the fall and responded to the incident. RN 1 stated that she could not recall the detail of the fall and that she no longer worked for the facility. RN 1 stated that usually the CNA would put the side rails down in order to set up the meal trays for patients that could feed themselves or for those that needed to be fed. RN 1 further stated that usually after meals the CNA would remove the tray and put the side rails up. RN 1 confirmed that the side rail was down on the side of the bed where the patient fell out of the bed. RN 1 could not recall if the breakfast tray was at the bedside at the time of the incident.On May 25, 2011 at approximately 2:05 PM, an interview was conducted with the current DON. The findings from the X-rays completed at the acute care hospital were discussed. The DON stated that she was part of the IDT that met on June 10, 2010 and discussed Patient A?s fall. The DON confirmed that Patient A fell out of bed on June 8, 2010. The DON stated that the side rail was down when Patient A fell out of bed because the patient was eating breakfast. The DON stated that based on the mobile X-rays completed at the facility on June 8, 2010, Patient A?s re-fracture did not occur at the facility. The DON stated that the re-fractures could have occurred when the patient went to her doctor?s appointment on June 10, 2010. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000099 |
Sierra Vista |
240009569 |
B |
24-Oct-12 |
73QL11 |
4222 |
REGULATION VIOLATION: Title 22 72527 Patient Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish 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.(9) Patients shall have the right to be free from mental and physical abuse. During the investigation of an entity reported incident on July 25, 2007, it was determined that the facility failed to ensure that Patient 1 was free from mental abuse by the facility's failure to intervene after CNA 1 demonstrated that she was verbally aggressive, volatile, and was overheard stating that she was tired of doing patient care.Record review revealed that Patient 1 was a 36 year old female admitted to the facility on June 29, 2005, with a diagnosis of mood disorder. During an interview conducted with Patient 1 on July 25, 2007, at 3:00 PM, she was alert and oriented and was observed to be teary eyed, wringing her hands together and shaking her legs up and down rapidly. Patient 1 stated that CNA 1 frequently called her, "A white bitch and a piece of shit." Patient 1 further stated that CNA 1 would threaten to tell the charge nurse to take away her (Patient 1's) smoke beaks and that CNA 1 would also threaten her and say, "You are never going to get out of this place." Patient 1 stated, "To be honest, I didn't say anything because I was afraid of her." During an interview with the Director of Staff Development (DSD) on July 25, 2007 at 3:30 PM, she stated that she had verbally counseled Certified Nurses Aide (CNA) 1 twice in June of 2007. The DSD further stated that CNA 1 was being "louder" than usual and sometimes would "incite the patients." Review of the DSD's interview narrative notes, dated June 16, 2007, revealed that CNA 1 was counseled about her attitude and her loudness on the unit. The note further showed that CNA 1 began yelling during the counseling and had to be told to calm down.Review of the DSD's written narrative note, dated June 28, 2007, revealed that CNA 1 had called off work and that the DSD had been informed by staff members that CNA 1 had made a statement that she was going to call off because she was tired of doing patient care.Further review of the narrative note showed that CNA 1 was told that she had a pattern of calling off and that it needed to stop. The note ended with a statement that CNA 1 needed to watch her call offs and watch her attitude on the floor.During an interview conducted with the Licensed Vocational Nurse (LVN 1) on July 25, 2007, at 3:15 PM, she stated that on the night of July 10, 2007, she was approached by Patients 1, 2, and 3.Patients 2 and 3 told LVN 1 that they had witnessed many episodes of verbal abuse by CNA 1, frequently directed at Patient 1. LVN 1 further stated that she had worked with CNA 1 in the past and stated that CNA 1 was "loud, obnoxious, and needed frequent redirection." On July 25, 2007, at 3:10 PM, during an interview conducted with Patient 2, he stated that CNA 1 had an "Attitude, and should have been living here with all of us. Everything I said in my report was true." In a written statement, July 10, 2007, Patient 2 wrote that he had witnessed CNA 1 swearing at Patient 1 and that as soon as CNA 1 came to work, she would put Patient 1 in time out.In a written statement, dated July 10, 2007, Patient 3 wrote that CNA 1 would swear at Patient 1 and tell her to be quiet even if Patient 1 was not talking. Further review of the written statement showed that Patient 3 documented that CNA 1 cursed at patients and woke everyone up in the morning by yelling up and down the hallway.During an interview conducted with the DSD on July 25, 2007 at 3:00PM, when asked if she felt that CNA 1 was appropriate to be caring for patients, the DSD did not reply. The facility failed to uphold Patient 1's right to be free from mental abuse. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 240000143 |
SHANDIN HILLS BEHAVIOR THERAPY CENTER |
240010442 |
A |
05-Feb-14 |
65KZ11 |
8613 |
REGULATION VIOLATION: F323 483.25(h) Accidents The facility must ensure that- (1) The resident environment remains as free from accident hazard as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to provide supervision to prevent accidents for Resident A, after Resident A had voiced delusional (having false belief) thoughts of leaving (the facility) and going back to the wilderness where he came from.The facility's failure to provide a safe environment and to supervise Resident A resulted in Resident A leaving the facility, using a facility ladder to climb up onto the roof of a building (the maintenance shed), and falling off the roof to the ground. Resident A was sent to an acute hospital emergency room and was diagnosed with pelvic/sacral (tailbone area) and left femur (thigh bone) fracture (broken bones) and suffered severe pain.On October 14, 2011, a review of Resident A's medical record was conducted. Resident A was 46 years of age, admitted to the facility on October 16, 2008 and had diagnoses that included Psychosis (an abnormal condition of the mind) manifested by delusional thoughts of having special powers, denial of mental illness, and Schizoaffective Disorder (a mental disorder characterized by distorted perception and episodes of elevated or depressed mood).A review of the nursing progress notes and change of condition documentation dated October 9, 2011, reflected that on October 9, 2011, at approximately 12:35 AM, Resident A walked out of the facility building, climbed up onto the roof of a maintenance shed (a one story building located behind the facility), and fell off the roof. Resident A landed on his left side, complained of severe lower back pain, and sustained a five (5) inch laceration (tear of the flesh) and bleeding on the right lower cheek. Resident A was unable to stand up due to severe lower back pain and was transferred and admitted to a general acute care hospital.On October 14, 2011, at 2:45 PM, a tour of the facility and surroundings was conducted with the facility Maintenance Supervisor (MS) and the Assistant Administrator (AA). The facility had an exit door located in the southern corridor which was alarm activated when opened but not locked. The exit door leads to the back area of the facility. In the back of the facility was a basketball court that was surrounded by a high chain-link fence. The chain link gate to the basketball court was unlocked and could be opened from the outside by anyone, including the residents. Inside the basketball court area was an 11 to 12 foot high maintenance shed building located on the east side of the basketball court. The surrounding ground around the maintenance shed where Resident A fell was made of concrete with loose gravel on top. In an interview with the AA and the MS on October 14, 2011 at approximately 2:50 PM, the AA stated that Resident A escaped out of the facility through the south corridor exit door. The AA explained the exit door was alarm activated when opened but unlocked and could be opened by anyone. The MS stated that a metal ladder was found placed against the edge of shed's roof and that Resident A used the ladder to climb up to the rooftop. The MS further stated that the ladder should not have been out of the shed, and he did not know why the chain link gate had been left unlocked from the outside. When asked if the chain link gate to the basketball court should be kept unlocked from the outside, the MS stated that the gate should be kept locked at all times except when (facility) staff was present in the area. Further interview with the AA on October 14, 2011, at 3:35 PM, the AA was asked for the facility's policy and procedure regarding the facility's grounds, resident safety and/or elopement. The AA stated the facility did not have a policy and procedure or protocol about the facility grounds, resident safety and/or elopement. When the AA was asked how Resident A got on to the roof of a building in the middle of the night on October 9, 2011, the AA stated, "To be honest with you, I don't have any answer for that." In an interview with Certified Nurse Assistant (CNA) 1 on October 14, 2011 at 3:10 PM, CNA 1 stated that on the night shift of October 9, 2011, at 12:35 AM, CNA 1 observed that Resident A was upset as he was walking in the hallway. CNA 1 stated, she heard Resident A saying he wanted to leave (the facility) and go outside to the woods for fresh air. CNA 1 stated, after a few minutes she and other staff heard the exit door alarm on the south side of building but they were busy providing care to another resident and could not immediately go and check to see who had opened the door. CNA 1 stated that by the time CNA 1 and CNA 2 were out at the back area of the facility, the area was very dark and there was no light in the basketball court area. With the use of a flashlight, CNA 1 and CNA 2 found Resident A walking and pacing back and forth on top of the roof of the maintenance shed. CNA 1 further stated that Resident A continued pacing back and forth then walked off the roof and fell to the ground.In an interview with CNA 2 on October 14, 2011 at 3:25 PM, CNA 2 stated that Resident A ran out of the building and got on top of the roof of the maintenance building. CNA 2 stated that Resident A did not want to get down and he just walked off the roof and fell to the ground. A review of the Psychiatrist's (a physician who specializes in the diagnosis and treatment of mental disorder) Assessment and progress notes dated September 22, 2011, which was 17 days prior to the fall incident, indicated Resident A was "Positive for Paranoia (having false belief)" and that he (Resident A) had stated he wanted to return to the wilderness where "I (Resident A) came from." Review of the physician's orders dated September 22, 2011 showed a dose increase of the resident's medication 'Haldol' (a drug used to treat mental disorder) injection from 100 milligram (mg) every 4 weeks, to 200 mg every 4 weeks.A review of Resident A's plan of care that began on February 16, 2008 and was last updated on May 25, 2011, noted Resident A's psychotic problems included delusional thought content manifested by grandiose (a fantastical belief of being powerful or famous) delusions of having special powers and denial of mental illness. The care plan interventions included: a. To utilize 'Pro-ACT' (verbal intervention and physical restraint) in response to residents psychosis related crisis behavior. b. To educate the resident about the symptoms of mental illness as they relate to psychosis in order to assist the resident in their acceptance of their mental illness. c. To educate the resident on the development of cognitive (mental process that includes memory and attention) and behavioral coping skills and strategies..." There was no documentation that the Interdisciplinary Team (IDT) had reviewed, revised, and implemented interventions to ensure Resident A's safety after the resident had voiced delusional thoughts of leaving (the facility) and going back to the woods. In an interview and a concurrent record review with the Assistant Administrator (AA) regarding Resident A on October 19, 2011 at 11:45 AM, he was asked whether or not safety measures were implemented for Resident A after the psychiatrist's assessment dated September 22, 2011 that noted Resident A's delusional thoughts of wanting "to return to the woods where I (Resident A) came from." The AA reviewed Resident A's medical record and was unable to find documentation that the IDT had reviewed the psychiatrist's assessment of Resident A's delusional thought of leaving the facility and going back to the woods. The AA further acknowledged that Resident A's plan of care had not been revised and updated to include interventions that addressed the safety needs of Resident A.The facility's failure to provide a safe environment and supervision to Resident A after Resident A had verbalized delusional thoughts of leaving the facility and going back to the woods resulted in Resident A leaving the facility unsupervised by staff, climbing to the roof of the maintenance shed with a facility ladder, and falling approximately 12 feet to the ground. Resident A sustaining a pelvic/sacral and left femur fracture. Resident A was subjected to severe pain and underwent hip surgery.The violation of the above regulations presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 240000099 |
Sierra Vista |
240011653 |
B |
13-Aug-15 |
H7MU11 |
6664 |
REGULATION VIOLATION: 72527(a) (10) 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.The facility failed to protect other patients from being verbally and physically abused by Patient 1. Patient 1 had been refusing medications. Patient 1 was assessed by the psychiatrist and was recommended to be transferred to a higher level of care. This failure resulted in Patient 1 verbally and physically abusing other patients. Patient 1 was readmitted to the facility on May 22, 2014 with diagnoses that included paranoid schizophrenia (mental disorder).During an interview with Patient 1, on November 18, 2014 at approximately 10:30 AM, Patient 1 was observed standing outside of his room. Patient 1 refused to be interviewed and began to yell at staff.An interview was conducted with Patient 2, on November 18, 2014 at 10:35 AM. Patient 2 was asked about the incident which occurred on October 31, 2014. He stated he was "ok" and did not want to talk about the matter anymore. A review of the "psychiatrist progress note", dated October 8, 2014, documented Patient 1 was diagnosed with unspecified schizophrenia (mental disorder). Patient 1 refused to be seen by the psychiatrist. Patient 1's medications were Haldol Decanoate (antipsychotic medication), Haloperidol (antipsychotic), Lorazepam (anti-anxiety) and Latuda (antipsychotic). The note indicated Patient 1 refused his medications, lab works, assessments and would not participate in the treatment program. The psychiatrist had suggested to transfer Patient 1 to an acute psychiatric facility. However, there was no documented evidence in the clinical record that the psychiatrist wrote an order for transferring Patient 1 to an acute psychiatric facility as suggested to the Assistant Director of Nurses (ADON).A review of the interdisciplinary treatment plan summary sheet documented Patient 1 had been experiencing physical aggression behavior since August 29, 2014.During a review of the discharge plan with the ADON, on November 18, 2014, the ADON confirmed there was no documented plan in the patient's clinical record for Patient 1 to transfer to a higher level of care which was suggested by the psychiatrist on October 8, 2014.A review of the physician's orders and physician's notes with the ADON, on November 18, 2014, revealed on October 20, 2014 the physician discontinued Patient 1's Haldol decanoate and Latuda due to Patient 1's refusal of all medications. During an interview with the ADON, on November 18, 2014 at 3 PM, he stated Patient 1 had been refusing his medications. The ADON stated he was there on October 8, 2014 when the psychiatrist recommended for Patient 1 to transfer to a higher level of care. The ADON stated he did not communicate the psychiatrist's plan with the social service or the administrative staff. During a review of the "change of condition documentation" notes, the patient incidents occurred as follows;On October 31, 2014, documentation reflects Patient 1 punched Patient 2 in the face four times for non-specified related aggression. Patient 1 suffered minor abrasions to his left hand knuckle and right side of the neck, and Patient 2 had no apparent injuries. There was no documented evidence in the clinical record that Patient 1's IDT treatment plan was updated or formulated addressing this specific incident. This was verified by the ADON.On November 15, 2014, documentation reflects Patient 1 punched a wall by the outside patio, which caused a hole on the wall. There was no documented evidence in the clinical record that Patient 1's IDT treatment plan was updated and formulated addressing this specific incident. The ADON verified that Patient 1's IDT treatment plan was not updated nor formulated addressing this incident. On November 16, 2014 at approximately 9:25 PM, documentation reflects Patient 1 exhibited verbal aggression towards Patient 3. There was no documented evidence in the clinical record that Patient 1's IDT treatment plan was updated or formulated to address this specific incident. The ADON verified that Patient 1's IDT treatment plan was not updated or formulated to reflect this incident. During an interview with certified nursing assistant (CNA) 1, on November 20, 2014 at 2:20 PM, she stated Patient 1 would pace the unit using profanity toward peers and staff daily. He would posture to fight towards certain patients and staff. He would stand by his room talking to himself, and put himself in a bad situation so his peers thought that he was yelling and cursing at them. Patient 1 refused his medications and care. During an interview with primary counselor (PC) 1, on November 20, 2014, at 2:30 PM, he stated Patient 1 will scream, yell and was very delusional (having false or unrealistic beliefs). He would argue and talk to himself. He would confront other residents directly. PC 1 stated he had noticed significant changes in Patient 1's behavior in the past months, especially after his antipsychotic medications were discontinued. Patient 1 became very difficult to deal with and he would not listen anymore.During an interview with the Administrator, on November 19, 2014 at approximately 11:40 AM, she stated she reviewed Patient 1's clinical record and determined the suggestion from the physician for Patient 1 to be placed in a higher level of care was over looked by staff and not carried out. During a review of the facility's policy and procedure, titled OPS302-CA "Abuse Prohibition " dated July 1, 2013, defines physical abuse "includes hitting, slapping, pinching, kicking, etc. It further defines verbal abuse, any use oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients regardless of their age, ability to comprehend, or disability " The policy further states the facility prohibits abuse for all patients. The facility failed to protect other patients from being verbally and physically abused by Patient 1. Patient 1 had been refusing medications. Patient 1 was assessed by the psychiatrist and was recommended to be transferred to a higher level of care. This failure resulted in Patient 1 verbally and physically abusing other patients. These violations had a direct relationship to the health, safety or security of the patients. |
| 240000143 |
SHANDIN HILLS BEHAVIOR THERAPY CENTER |
240011786 |
B |
24-Nov-15 |
JZCE11 |
4010 |
REGULATION VIOLATION: 72315 (b), Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. 72527(a) (10) 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. FINDINGS The facility failed to ensure Patient 1 was protected from verbal and physical abuse by staff. On September 29, 2014, a Certified Nursing Assistant (CNA) hit Patient 1 on the back of the head with a closed fist. This failure resulted in Patient 1's rights to be free from abuse were violated.On October 1, 2014 at 3:30 PM; the surveyor met with Patient 1 and it was observed that the patient was alert and verbally responsive.Review of the clinical record for Patient 1, documented that Patient 1 was admitted to the facility on June 6, 2014 with diagnoses that included schizoaffective (mental illness with deregulated emotions and insomnia (inability to sleep). Patient 1 had a psychiatric history of hearing voices, paranoia, mood swings, depression, manic behavior, depression and assault.During an interview with Patient 1 on October 1, 2014 at 3:30 PM (afternoon), in the dining room, he was asked about the incident that occurred on September 29, 2014. He stated, "I was hearing voices and began screaming about Christ and death." Patient 1 further stated that he (the patient) hit CNA 1 on the left top side of the lip and pulled her hair. Patient 1 stated that someone hit him on the head right after hitting CNA 1. A review of the Behavior Care Plan dated June 9, 2014, indicated that Patient 1 exhibits physical aggression towards staff. Staff intervention consists of stable and routine setting; rules, consequences and social counseling.An interview was conducted with the director of nursing (DON) on October 1, 2014 at 2:55 PM, he stated on September 29, 2014, he was coming down the hall way and saw Patient 1 in Proact restraint (The use of staff's body to restrict the patient's movement to prevent the patients from injuring themself or others) on the floor assisted by maintenance staff (MS) and three nursing staff. Patient 1 was observed holding on to CNA 1's hair. The DON stated he helped remove Patient 1's hand from grasping CNA 1's hair. Patient 1 then released CNA 1's hair. CNA 1 got up and curses at Patient 1 "Oh no M... F..." then CNA 1 hit Patient 1 with a closed fist to the back of the patient's head behind the right ear. The DON stated CNA 1 should have not hit Patient 1's head. CNA 1 was immediately removed from the unit. CNA 1 was terminated and was not available for interview during the investigation.A review of CNA 1's employee file, documented that CNA 1 was hired on April 21, 2014 and was terminated on September 29, 2014. Continued review of the file showed CNA 1 was provided Abuse prevention in-service on April 21, 2014. A review of the facility policy and procedure titled, "OPS302-CA Abuse Prohibition", dated July 1, 2013, documented "[Facility name] will prohibit abuse...for all patients... Verbal abuse is any use of oral...or gestured language that willfully includes disparaging and derogatory terms to patients regardless of their age, ability to comprehend, or disability. Physical abuse includes hitting..." The facility failed to ensure Patient 1 was protected from verbal and physical abuse by staff. On September 29, 2014, a Certified Nursing Assistant (CNA) hit Patient 1 on the back of the head with a closed fist. This failure resulted in Patient 1's rights to be free from abuse were violated.These violations had a direct relationship to the health, safety or security of the patients. |
| 240000682 |
Sky Harbor Care Center |
240012158 |
B |
01-Apr-16 |
XN1C11 |
6995 |
REGULATION VIOLATION: 72527(a)(10): (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse.FINDINGS The facility violated the above mentioned regulation by failing to: Protect one out of three sampled patients (Patient A) from physical and emotional abuse by a staff member when a Certified Nurse Assistant (CNA 1) pinched and twisted Patient A's nipple on several occasions, and would not stop when requested to stop by Patient A. This resulted in Patient A experiencing physical and emotional abuse. On March 9, 2015 at 10:00 AM, an unannounced visit was made to the facility to investigate an entity reported incident of physical abuse to Patient A. During an interview with the Administrator and the Director of Nursing (DON) on March 9, 2015 at 10:00 AM, the Administrator stated, "We called in and reported the Entity Reported Incident (ERI) as soon as we heard about it. We also called [name of law enforcement agency], and they came and interviewed the patient." The Administrator and DON stated, "The patient is unsure of the exact date it first happened, and CNA 1 denies everything, but he was suspended right away." During an interview with Patient A on March 9, 2015 at 2:00 PM, he stated, "He [CNA 1] penned (poked/ touched his nipples with a pen) and touched my nipples using his fingers over and over. I asked him to stop but he wouldn't stop. It was painful, and he wouldn't stop, and he didn't say anything." Patient A stated, "Another time he was sitting in a chair and I was in the wheel chair, and he did it to me. Sometimes I'm lying in bed and he does it too, it's tortuous. He's [CNA 1] been doing it a couple of weeks and I've told everybody. I feel better now that he's gone. Somebody called the Sheriff's Office and they talked to me too. People like that should not be working here."An interview was conducted with CNA 2, on March 9, 2015 at 12:45 PM, in the presence of the Director of Staff Development (DSD). CNA 2 stated, "I saw him [CNA 1] flick the nipples of Patient A. When CNA 1 and I were passing trays, Patient A wanted to go back to bed. I can't remember the exact date, but it was either Saturday or Sunday last week (February 28, 2015 or March 1, 2015), but it was after breakfast in the morning about 9:00 AM. CNA 1 was behind the patient's [Patient A's] wheel chair and he reached over and flicked Patient A's nipples, and said to me, 'He [Patient A] likes it when I play with his nipples. I told CNA 1, "You're stupid." The patient [Patient A] said to me, "You would like it if I played with yours." I said to Patient A, "You're gross, don't talk to me like that." Patient A said, "You won't be saying that when I'm done." CNA 2 also stated during the interview, "When we moved the patient [Patient A] to bed, CNA 1 got on one side of the patient, I got on the other side, and using a gait belt we put the patient in bed. I was uncomfortable with what the patient said to me and I left the bedroom." CNA 2 admitted she did not report these abuses she witnessed to a supervisor. During a review of the facility's policy and procedure entitled, "Abuse Prevention & Elder Justice Program," dated July 2013, the policy set forth under section (b) of "Inter-facility Reporting Responsibilities," the following provisions: "All employees are mandated reporters of abuse,...therefore, if any employee becomes aware of an allegation or suspicion of abuse, or inappropriate conduct and fails to report it as required by law, that employee will be subject to disciplinary action, up to and including termination of employment." During an interview with CNA 1 in the presence of the Director of Staff Development on March 09, 2015 at 2:45 PM, he stated, "I don't know what he [Patient A] is talking about. When I'm putting him [Patient A] to bed, I'm lying him down and I have only touched his chest and belly. For about two weeks, I was waking him by rubbing him on his belly, and he complained about that, so I then started shaking his chest and he doesn't complain about that. I usually get another CNA to help me move him. Patient A tends to be the kind of patient who urinates when you get close to him. I don't know why he made these accusations about me." During a record review on March 9, 2015, of a facility document entitled, "Interview/ Debriefing Narrative Records," of CNA 3, dated March 05, 2015, CNA 3 indicated: "I was told by [Patient A's name], that [CNA 1's name] has been pinching him various places and giving him titty twisters (a person pinches then twists another's nipple)." A review of Patient A's clinical record conducted on March 9, 2015, revealed Patient A was admitted to the facility on May 26, 2011, with diagnoses which included: Diabetes Mellitus (the body cannot produce or utilize insulin to control blood sugars); coronary artery disease (CAD- the arteries around the heart narrow), and Alzheimer's Disease (AD- a form of dementia which seriously affects a person's ability to carry out daily activities). During a review of CNA 1's employee records on March 9, 2015, the record reflected CNA 1 had attended abuse training on September 25, 2014. The training included all of the following: respectful workplace policy, facility orientation, abuse prevention, handbook, dementia, Alzheimer, code of conduct, code of ethics, patient's bill of rights, patient's rights, HIPPA, abuse, and neglect. During review of documentation in CNA 1's employee file, the documentation indicated CNA 1 was suspended from work on March 5, 2015 for allegations of abuse, and his employment was terminated on March 9, 2015.During a review of the facility's policy and procedure entitled, "Abuse Prevention & Elder Justice Program", dated July 2013, the policy indicated: "Each patient has the right to be free from all forms of abuse (verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusions, mistreatment, neglect, and misappropriation of money or property.This facility works to ensure that its patients are not subject to abuse by anyone, including but not limited to facility staff, other patients, consultants or volunteers, staff of other agencies serving the patient, family members or legal guardians, friends, or other individuals. All forms of abuse are strictly prohibited by this facility." The policy defined "physical abuse" as follows: "hitting, slapping, pinching, kicking, and includes controlling behavior through corporal punishment." The facility failure had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients. |
| 240000136 |
SYCAMORE HOUSE |
240012170 |
B |
07-Apr-16 |
3RZH11 |
5824 |
REGULATION VIOLATION: Welfare and Institutions Code 4502. Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of this 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 provide a safe environment free from physical and verbal abuse affecting two of six clients (Clients 1 and 2) residing in the facility. This failure had the potential to result in an increased risk for abuse to occur for a universe of 6 clients residing in the facility. Findings: 1. A review of Client 1's medical records indicated, Client 1 was admitted to the facility on October 28, 1985 with diagnoses that included profound mental retardation (severe learning and developmental disability) and aggression. A review of the facility's investigative report dated March 17, 2013, indicated the Facility Manager (FM) reported she had witnessed Direct Care Staff 1 (DCS 1) hit Client 1 on the arm and chest area. The investigative report indicated an interview was conducted by the Qualified Intellectual Disability Professional 1(QIDP 1) with DCS 1, in which DCS 1 admitted to raising his hand and made it look like he was going to hit Client 1. A review of Client 1's physical abuse incident, a written declaration from the FM indicated the following statement, "On March 17, 2013, after dinner time...I heard Client 1 crying from his room so I rush down the hallway to see what the matter was and as I peeked in his room, I saw DCS 1 straddled over Client 1, hitting him forcefully on his right arm and on the chest area. I saw that and I quickly jumped back...DCS 1 kept watching me and giving me weird looks that made me want to stay clear of him so I waited until it was time to leave to make a phone call. DCS 1 followed me outside.. I started driving off and began to call the QIDP and spoke to the police...I feared for my life."During a follow up visit and observation on October 16, 2014 at approximately 3:45 PM, with the QIDP 2, Client 1 was outside on the patio. He was calm and quiet but was unable to communicate when spoken to.In a concurrent interview with the QIDP 2, he confirmed, Client 1 was "non-verbal." He stated he could not give any information about the abuse incident because he was not the QIDP at the facility during that time. He stated, the Facility Manager and current staffs were new to the facility and not familiar with the incident. 2. A review of Client 2's medical records indicated, Client 2 was admitted to the facility on December 3, 2009 with diagnoses that included profound mental retardation (severe learning and developmental disability) and quadriplegia (paralysis from neck down to the legs). A review of the facility's investigative report on March 17, 2013, indicated the Facility Manager (FM) reported she had witnessed DCS 1 hit Client 2 on the hand and yelled at him at dinner time.A review of Client 2's physical and verbal abuse incident, a written declaration from the FM indicated the following statement, "On March 17, 2013 during dinner time... Client 2 was eating his food with his bare hands. DCS 1 decided to smack Client 2 on top of his hand and yelling at him to stop eating with his hands. Client 2 jumped in his seat and proceeded to pick up his spoon and begin to continue eating." During an observation of Client 2 on October 16, 2014 at 4:20 PM, he was sitting on his wheelchair, awake and alert, however he was not able to communicate. During an interview with the QIDP 2 on October 16, 2014 at 4:30 PM, he stated he was not the QIDP at the facility when this incident of abuse happened. He stated the current FM and the staff were new to the facility. In a telephone interview with QIDP 1 on October 14, 2014 at 10:30 AM, she said she substantiated the abuse allegations. She stated an employee had witnessed DCS 1 slapping Clients 1 and 2. She further stated that DCS 1 denied to actually hitting the clients. QIDP 1 stated DCS 1 was threatening the clients by pretending he was going to hit Client 1. She stated, "He raised his hands as if he was going to hit Client 1, that's considered an abuse." The QIDP 1 stated the previous Facility Manager quit after the incident. She stated there were no other witnesses to the abuse. She stated current staff were new to the facility. A review of the facility's policy and procedure titled, "Prevention of Abuse, Neglect and Mistreatment Policy," read in parts, indicated, " The following policies outline practices for the prevention of abuse, neglect and mistreatment and include the following components: Protect.. in the event an individual receiving facility services has been accused of or has engaged in abuse, the Administrator will make the environment changes necessary to prevent a similar occurrence from being repeated. Prevent. The following special incidents shall be reported to the regional center if occurred during the time the consumer was receiving services and support from any vendor or long term health care facility:...reasonably suspected abuse/ exploitation including 1. physical. 4. emotional/mental." The above violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 240000682 |
Sky Harbor Care Center |
240012221 |
B |
02-May-16 |
FNEC11 |
5042 |
Regulation Violation: 72527 Patients' Rights (a)Patients have the rights enumerate in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse.The facility violated the above mentioned regulation by failing to: Protect one sampled patient (Patient A) from emotional abuse by a staff member when a Certified Nurses' Aide (CNA 1) yanked the urinal off the patient's penis while Patient A was in the process of using the urinal. CNA 1 was aggressively yelling at the patient using foul language, slammed the urinal on the bedside table, picked up a toothbrush and snapped it in half. This resulted in Patient A experiencing verbal and emotional abuse.On April 6, 2015 at 11:00 AM, an unannounced visit was made to the facility to investigate an entity reported incident of emotional and verbal abuse to Patient A. During an interview with the Director of Nursing (DON) on April 6, 2015 at 11:00 AM, the DON stated, "The alleged incident happened on December 23, 2014, but Patient A reported the incident to a CNA 2 on December 26, 2014. The allegation was reported to CDPH, Ombudsman, and a law enforcement agency. The CNA 1 was initially suspended and then terminated after investigation was completed."During an interview with Patient A on April 6, 2015 at 12:00 PM, he stated that he feels better that CNA 1 was already gone. He stated, "CNA 1 was rough and took away the urinal while I was using it. CNA 1 was angry, yelling and threatening." Patient A stated further, "I feel safe here in the facility but if I get discharged into the community I am afraid. What will happen if I see that person (referring to CNA1) in shopping area?" Patient A was asked to whom he reported the incident, he stated to another CNA (CNA 2).During a record review on April 6, 2015, of CNA 2's undated written report, the report indicated, "I came in on December 25, 2014, and checked my patient (used Patient A's name and room number), and stated he [Patient A] was trying to use a urinal for about an hour. He [Patient A] could not go which is normal. He [Patient A] told me that (CNA 1's name) a PM shift CNA tore away the urinal from his penis, told the resident to "give me that f__ng s__t) pulling the urinal away from (used Patient A's name) penis. Right away I also confirmed with (used CNA 1's name) what resident stated and (used CNA 1's name) admitted he did it because he was tired of waiting on the resident to finish peeing in the urinal." A review of Patient A's clinical record conducted on April 6, 2015, revealed Patient A was admitted to the facility on December 18, 2014, with diagnoses which included: Diabetes Mellitus (the body cannot produce or utilize insulin to control blood sugars); cardiac arrhythmia (improper beating of the heart), hypertension (high blood pressure), heart attack, and neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet). Patient A's history and physical completed by the physician on December 21, 2014, indicated that Patient A is capable of making decisions. A phone interview with CNA 2 was conducted on April 8, 2015 at 9:50 AM. CNA 2 stated that Patient A reported to him that CNA 1 ripped a urinal off Patient A's penis. CNA 2 stated he came up to CNA 1 and asked him if the incident reported by Patient A was true, and CNA 1 admitted he did it.A review of documentation in CNA 1's employee file was completed on April 6, 2015, the documentation indicated CNA 1 was suspended from work on December 26, 2014 through December 29, 2014, for allegation of abuse. CNA 1 was terminated from employment on December 30, 2014. An email was sent by the Director of Staff Development (DSD) to the CNA Board dated December 26, 2014, informing them of CNA 1's alleged abuse.During a review of the facility's policy and procedure entitled, "Abuse Prevention & Elder Justice Program," dated July 2013, the policy indicated: "Each resident has the right to be free from all forms of abuse (verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusions, mistreatment, neglect, and misappropriation of money or property). This facility works to ensure that its residents are not subject to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. All forms of abuse are strictly prohibited by this facility." The policy defined, "physical abuse as hitting, slapping, pinching, kicking, and includes controlling behavior through corporal punishment." The facility failure had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000682 |
Sky Harbor Care Center |
240012512 |
AA |
16-Aug-16 |
87TP11 |
22091 |
REGULATION VIOLATION Quality of Care ?483.25 - Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Accidents F323 ?483.25(h) - 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. Findings: On December 7, 2015 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 provide supervision to ensure the safety of Resident A, who had a repeat history of leaving the facility without staff knowledge, resulting in multiple falls with injuries. Resident A had falls on the following dates: a. July 3, 2015-Resident A was found outside of the facility parking lot. His wheelchair got stuck in the dirt and he fell out of the wheelchair, b. July 9, 2015?Resident A had a fall from his wheelchair, c. August 11, 2015-Resident A had an unwitnessed fall, d. December 7, 2015-Resident A was observed out of facility with his wheelchair flipped, and e. December 9, 2015?Resident A had an unwitnessed fall outside. In addition, the facility failed to identify and implement appropriate and progressive care interventions for Resident A and failed to modify Resident A?s care plans so as to prevent a reoccurrence of falls or elopement attempts. As a result, the facility failed to provide and for Resident A to receive necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. As a result of all of these failures, the regulations cited previously herein were violated, for which caused Resident A?s unsupervised fall from his wheelchair outside of the facility, cervical spine (neck) fracture and blunt force trauma, and ultimately, Resident A?s death. On December 7, 2015 at 4:40 PM, Resident A was observed eating in the dining room with his responsible party (RP) by his side. Resident A was observed to have a left eye injury with red and purple discoloration around the outer edges of it, with bandage strips on the left temple area. During a concurrent interview with Resident A's responsible party (RP), she stated that Resident A fell on the morning of December 7, 2015, while he was outside, alone, in his wheelchair. He hit some dirt, causing his wheelchair to tip over so that he hit his head. A concurrent interview was conducted with Resident A, in which he stated, "I do not remember what happened." On December 7, 2015 at 4:45 PM, an interview was conducted with a Registered Nurse (RN 1). RN 1 stated Resident A has dementia and wanders. RN 1 stated a passerby found Resident A and brought him back into the facility. RN 1 further stated the facility's protocol following a head injury included doing frequent visual checks (knowing the resident's whereabouts) and monitoring the resident for 24 hours. During a review of Resident A?s paper clinical record, the face sheet (containing resident demographics) revealed that Resident A was an 85 year old male re-admitted on June 20, 2014 with diagnoses which included: a history of falls, severely impaired cognitive functioning (which includes attention, memory, judgment, and reasoning), Alzheimer's disease (disorder that attacks the brain's nerve cells; mental decline), dementia (brain disease that causes memory disorders, personality changes, confusion, and impaired reasoning), and seizure disorder (convulsions-uncontrolled electrical activity in the brain). A review was conducted of Resident A?s Nursing Admission Assessment form, dated June 20, 2014, which indicated, Resident A was alert, oriented (to person, place, time, and situation), and cooperative, however, Resident A could be verbally aggressive and disruptive. The Nursing Admission Assessment form further indicated that Resident A was at risk for falls, as evidenced by a score of 16. The form indicated a total score of 8 or more in either category [Initial Fall Risk Assessment] requires a care plan to address risks and prevention. During a review of Resident A's "Elopement Risk Assessment" dated July 3, 2015, it indicated the resident had limited/poor safety awareness and judgment, verbalizes a strong desire to leave the facility, and purposeful wandering or exit seeking behavior. The form further indicated Resident A was at risk of eloping, with an overall score of 8. The Elopement Risk Assessment form indicated a score of seven or more requires elopement risk care plan. The form further asks whether the resident has a ?known history of one or more elopements from home or facility and has cognitive or safety deficits...If YES, develop elopement risk care plan with the need for secured unit/facility placement.? The facility failed to answer this question, although the resident had eloped from the building on April 20, 2015. There was no documented evidence that any reassessments of Resident A?s elopement risk had been conducted following repeated elopement attempts on December 7, 2015 or December 9, 2015, both which resulted in severe injuries. During a review of Resident A's ?Nurse Progress Note,? dated December 7, 2015, it indicated, ?At 0740 [7:40 AM], pt. [patient] was observed outside of facility with wheelchair flipped.? The resident was returned to his room where an assessment was conducted. ?Upon assessment, wheelchair tracks found near 400 hall. Body assessment performed, pt. [patient] noted to have laceration [deep cut] to left temple measuring 3.0 cm [centimeters] x [by] 1.5 cm, swelling to left eye/cheek area, hematoma [a solid swelling of clotted blood] to left cheek/eye area, an abrasion [scrape] to left knee measuring 2.0 cm x 1.5 cm, an abrasion to left outer knew measuring 1.5 cm x 2.5 cm, bruise to left top of wrist?? When the licensed vocational nurse (LVN) interviewed Resident A, the Resident stated, ?I was going for a ride!? There was no documented evidence that Resident A?s injuries or his whereabouts after being found outside with his wheelchair flipped over and sustaining facial injuries on December 7, 2015, was completed on the7:30 AM to 3:30 PM shift on December 8, 2015, or on December 9, 2015. There was no documented evidence that any reassessments of Resident A?s elopement risk had been conducted following repeated elopement attempts on December 7, 2015 or on December 9, 2015. There was no documented evidence that the facility?s policy and procedure entitled, ?Elopement Prevention and Management,? dated 2013, had been followed. The policy indicated the following: ?Procedure 1. Residents who are at risk for elopement (those residents with a clear history of repeated elopements) will have an appropriate plan of care developed to address the risk?6.The licensed nurse shall document all appropriate information in the clinical record before he/she ends his/her shift pursuant to the general documentation policy. All charting reports should be completed before leaving. This may included, but not limited to: a. When the resident was last seen and by whom. b. What the resident?s mental /cognitive status was prior to elopement.? On December 9, 2015 at 6:25 AM, an interview was conducted with the Administrator. The Administrator stated the outer doors are secured. She further stated the doors are locked from the outside, not the inside, with the exception of resident access areas/patios. The Administrator stated the doors are alarmed from dusk to dawn but were not alarmed this morning (December 9, 2015) because of anticipation of the survey team. She stated family members know to enter a certain door after hours. The Administrator stated the staff was in-serviced on December 7, 2015, about securing the facility following Resident A eloping because the alarms were not set. When asked if the Administrator had a written policy on securing the facility, she stated, "We do not have a policy, we have protocols." She stated the protocols were not written. When asked who monitors the front door entrance, the Administrator stated the facility has cameras however, several of the cameras did not work because the facility was being re-wired. During an interview with a licensed vocational nurse (LVN 3) on December 9, 2015 at 7:40 AM, when asked about the facility?s camera monitoring system, she advised that the TV (televisions) monitor only provides a view of the smoking patio, but that It does not provide a view of the 300 hall [where Resident A resided]. LVN 3 also advised that she could not remember if the TV monitor was on the evening of December 8, 2015. During an interview with a registered nurse (RN 3) on December 9, 2015 at 7:45 AM, she stated, ?The TV monitor was not on last night. It monitors the smoking patio, not the front entrance.? Further, RN 3 advised that No one particular staff is assigned to watch the TV monitor. On December 10, 2015 at 4:30 PM, an interview was conducted with the Administrator. The Administrator stated that Resident A fell the previous night [December 9, 2015]. A review was conducted of Resident A's ?Nurse Progress Note,? dated December 9, 2015, which indicated the following: ?2130 [9:30 PM] resident found outside in driveway in bushes with wheelchair on top. Called 911. Hematoma (a solid swelling of clotted blood) to right eye and bleeding to head. A+O x2 [alert and oriented times two].? The notes also indicated that the responsible party and physician were made aware. On December 11, 2015 at 9:00 AM, an interview was conducted with Resident A's RP. The RP stated Resident A was unable to push the doors open by himself. The RP further stated that she got a call from a Registered Nurse (RN 2) on December 9, 2015, and was informed by RN 2 that a pizza delivery person came and was responsible for letting Resident A go out of the front door. The RP stated Resident A was found in the front driveway near the church with the wheelchair on top of him by a passerby, and that he was in the Intensive Care Unit [of a general acute care hospital] with a fractured (broken) neck and facial fractures that he sustained in the fall. On December 11, 2015 at 11:32 AM, an interview was conducted with a Licensed Vocational Nurse (LVN 1). LVN 1 stated that Resident A wanders at times. LVN 1 stated Certified Nurse Assistants are told to check every 15 minutes if the resident is on shadow checks [staff do visual checks every 15 minutes and document the location of a resident for 24 hours after a fall], and every 30 minutes to monitor where the resident was in the building. LVN 1 stated she could not recall if Resident A was on shadow checks at the time of his elopement on December 9, 2015. On December 11, 2015 at 12:30 PM, an interview was conducted with the Director of Nursing. The DON stated she had shadow check documentation for December 7, 2015. The DON further stated that shadow checks were done for 24 hours [following an incident], then they stop and nurse's document visual checks every shift on the nurse progress note. The DON was unable to provide documented evidence for Resident A being monitored using visual checks every shift as provided on the nurse progress note on the day shift 7:30 AM to 3:30 PM on December 8, 2015, and on December 9, 2015between 1:35 AM, and 9:30 PM, when Resident A was found outside of the facility by a visitor to the facility. On December 11, 2015 at 3:00 PM, an interview was conducted with the Registered Nurse Supervisor (RNS). The RNS stated the facility did not have a list of residents who were at risk for elopement. There was no system in place to identify those at risk to elope. On December 11, 2015 at 4:00 PM, an interview was conducted with a Licensed Vocational Nurse (LVN 2). LVN 2 stated Resident A has been on shadow watches [checks] quite a few times because he threatened to leave the facility. LVN 2 further stated usually the CNAs document on the shadow check sheet and a licensed nurse does a note during the shift. LVN 2 stated she would look for the resident every 15 minutes and make sure he [Resident A] was safe when he was on shadow checks. On December 11, 2015 at 5:00 PM, an interview was conducted with the Registered Nurse (RN 2) who was on duty the evening of December 9, 2015, [time unknown] when Resident A left the facility without staff being aware he was gone. RN 2 stated she was at the nurse's station when a gentleman came up to her saying there was a man in a wheelchair, in the front driveway. RN 2 stated she did not know if the gentleman reporting this was a pizza delivery person, or visitor, and was uncertain how the gentleman got into the facility. RN 2 stated she asked a Certified Nurse Assistant (CNA 1) to help, and then she followed the gentleman to the main entrance door. RN 2 stated when she walked up to the main entrance door, the banner [a yellow banner to discourage people from exiting the front doorway after dusk] was on the ground. RN 2 stated she exited the main entrance door and saw Resident A lying toward the curb at the end of the driveway with his wheelchair on top of him. RN 2 stated the wheelchair was removed from on top of Resident A and 911 was called from CNA 1's cell phone. RN 2 further stated that she was aware of the fall Resident A had on December 7, 2015, and that she believed shadow checks were over. During a review of the facility's policy and procedure, entitled "Elopement Prevention and Management," dated July 2013, the policy and procedure indicated, "It is the policy of this facility to minimize the risk of elopement and take action to locate a missing resident.? The Procedure section indicated, ?1. Residents who are at risk for elopement (those residents with a clear history of repeated elopements) will have an appropriate plan of care developed to address the risk... 6. The licensed nurse shall document all appropriate information in the clinical record before he/she ends his/her shift pursuant to the general documentation policy. All charting and reports should be complete before leaving?a. When the resident was last seen and by whom?" A review of Resident A?s care plans included four care plans related to Resident A?s risk of elopement as follows: a. "Non-Compliance" dated November 30, 2014. A subsequent entry dated December 7, 2015, was added under ?approaches/action,? to ?redirect when verbalizing desire to leave the facility.? b. ?Potential for Wandering/Elopement? dated April 20, 2015, included documented approaches outlined on the care plan as follows: -Patient location charting Q15 [every 15 minutes] + prn [as needed]. -Monitor episodes of elopement attempts. -Will D/C [discharge] to locked secured facility when available. -A subsequent entry dated December 7, 2015, indicated staff were to, ?redirect when verbalizing desire to be elsewhere. c. ?Elopements? dated July 3, 2015, identified risk factors to include the desire to leave the facility. The documented approach outlined on the care plan dated July 3, 2015 included: Monitor elopement attempts. Allow resident to go out onto smoking patio with supervision . Patient location charting prn (as needed). A subsequent note was added on December 9, 2015, to the care plan for an intervention for ?frequent checks.? d."Potential for Falls" dated June 20, 2014, included subsequent documentation as follows: July 9, 2015- fall from wheelchair. No new interventions or cause of fall were identified. August 4, 2015- ?Falling Leaf Program? (the use of a falling leaf picture to cue staff that a resident is a fall risk) was listed under interventions. August 11, 2015- Unwitnessed fall, with an intervention added to ?Complete fall risk assessment on admission and after fall." December 9, 2015, listed ?unwitnessed fall outside,? and the addition of - ?Frequent checks,? which was not defined. -Redirect when verbalizing desire to leave facility. The documented approach outlined on the care plan dated December 7, 2015 included: -Alarm hallways/unit exterior doors. The resident?s care plan entitled ?Potential for Wandering,? dated April 20, 2015, outlined pre-printed approaches/actions, as follows: ?Monitor resident location Q [each] shift.? However, this intervention was left blank which indicated it was not selected to be implemented by staff. There was no documentation the facility had attempted to place Resident A in a locked secured facility as indicated in the care plan entitled, ?Potential for Wandering/Elopement,? dated April 20, 2015. There was no documented evidence the facility?s interdisciplinary team (IDT- consists of clinical department staff) had assessed the reason Resident A repeatedly attempted to elope, or that the IDT had identified and implemented interventions to prevent a reoccurrence. There was no specified frequency of how often Resident A was to be monitored after the ?Shadow checks? were completed. A review of the updated interventions for elopement after Resident A left the facility, fell, and sustained injuries on December 7, 2015, reflected a plan for staff to ?redirect when verbalizing desire to go elsewhere.? The elopement assessment indicated that Resident A scored a ?3,? which indicates ?verbalizes strong desire to leave the facility.? On Resident A?s care plan, under risk factors for elopement, it indicated a ?desire to leave facility.? A review of Resident A?s care plan for ?Potential for Falls,? dated as initiated on June 20, 2014 and updated March 24, 2015, indicated that Resident A had confusion, seizures, attempts to stand and/or transfer self, poor safety awareness, increased weakness, poor endurance, and history of falls, and indicated the staff were to conduct frequent visual checks, alarm hallway/unit exterior doors, and redirect when verbalizing desire to go elsewhere. A review was conducted of Resident A's Interdisciplinary Team (IDT) Meeting Note, dated July 6, 2015, which indicated, "On 7.3.15 [July 3, 2015] @ [at] approx. [approximately] 1700 [5:00 PM], resident was found outside of facility in parking lot by staff. Resident stated he was trying to go to hardware store. Resident w/c [Resident's wheelchair] got stuck in dirt and resident fell out of chair. Resident sustained S/T [skin tear] to forehead and left elbow...Resident on frequent visual checks by staff to ensure safety. MD/RP aware. Will monitor." There was no documented evidence on how frequently visual checks would be done by staff to, ?ensure safety,? or what specifically the staff had been directed that they, ?Will monitor.? The ?Potential for Falls? care plan, dated as initiated on June 20, 2014 and revised on March 24, 2015, reflected Resident A had an ?unwitnessed fall,? on August 11, 2015, however, there was no documentation to indicate where the fall occurred or interventions identified to prevent a reoccurrence. A review of Resident A?s general acute care hospital (GACH 1) medical record was conducted following the fall from his wheelchair on December 9, 2015. Resident A was admitted to the emergency department (ED) of GACH 1 on December 9, 2015 for a hematoma [a solid swelling of clotted blood] to the right cheek after a fall from wheelchair. The CT scan report (an x-ray test in which a computer takes a cross-section of a person's anatomy), dated December 9, 2015, indicated ..."Acute depressed right orbit floor (the bones of the eye socket) fracture into the maxillary sinus [broken facial bones]...Acute type III odontoid fracture of the cervical spine [broken neck bone].?The ?ED Physician Summary,? dated December 9, 2015, indicated Resident A was to be transferred to another hospital (GACH 2) due to requiring a higher level of care and neurological consultation. During a review of Resident A?s medical record from GACH 2, the ?Admission Record? indicated he was admitted on December 10, 2015, with diagnoses which included: acute type III odontoid fracture, right orbital floor fracture, and right maxillary sinus fracture. Resident A?s ?Magnetic Resonance Imaging [MRI; a technique using a magnetic field and radio waves to create detailed images of the organs and tissues within the body] of the cervical spine report, dated December 11, 2015, indicated, ??Inflammation in the prevertebral soft tissues from C1-C4?Ligamentous injury cannot be excluded.? A ?Neurosurgery Progress Note,? dated December 11, 2015, indicated, Resident A was confused, but alert. A review was conducted of Resident A?s ?Trauma Progress Note,? from GACH 2, dated December 12, 2015, which indicated, ?Patient had a cardiopulmonary arrest [loss of heart function, breathing, and consciousness] overnight. He is currently intubated?His chance of having a meaningful recovery and survival over the next 6 months is extremely low?? During a review of Resident A?s hospital physician ?Progress Note-Pulmonary and Critical Care,? dated December 12, 2015, it indicated, ?Overall prognosis for this patient is poor?He now has high cervical spine fracture?His chances of having any meaningful recovery is 0%. His survival over the next 6 months is close to 0%.? A review was conducted of Resident A?s ?Certificate of Death,? dated December 22, 2015, which indicated date of death was 12/12/2015 [December 12, 2015], and that the cause of death was (A) cervical spine fracture [and] (B) blunt force trauma.? The facility failed to provide supervision to ensure the safety of Resident A, and the facility?s failure to identify and implement care interventions specific to the needs of Resident A regarding his recurrent falls and elopement attempts, resulted in Resident A sustaining a cervical spine fracture and blunt force injuries, after Resident A eloped from the facility without staff noticing. The above violations presented imminent danger of death or serious harm, or a substantial probability of death or serious physical harm, and were the direct proximate cause of Resident A?s death. |
| 240000143 |
SHANDIN HILLS BEHAVIOR THERAPY CENTER |
240012565 |
A |
8-Sep-16 |
Z5N011 |
15982 |
REGULATION VIOLATION Title 22, California Code of Regulations, Division 5, Article 3, Section 72311: (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. Title 22, California Code of Regulations, Division 5, Article 3, Section 72521: Administrative Policies and Procedures. (a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. (b) All policies and procedures required by these regulations shall be in writing and shall be carried out as written. They shall be made available upon request to patients or their agents and to employees and the public. Policies and procedures shall be reviewed at least annually, revised as needed and approved in writing by the governing body or licensee. The facility failed to develop an individual care plan indicating the type of care to be given and objectives to be accomplished as evidenced by not having consistent supervision of the patient who had a history of suicidal behavior, self-harm attempts, and was a danger to self. In addition, the facility failed to develop and implement written policies and procedures to ensure that a closet, with an exposed sprinkler pipe, be unlocked and relocked by staff to ensure patients did not have access to this dangerous area. On February 21, 2013, Patient A was discovered in his room, inside the unlocked closet, hanging from the exposed sprinkler pipe with a belt around his neck. These failures resulted in the death of Patient A. An unannounced visit was made to the facility on February 21, 2013, at 4:45 PM, to investigate an entity self-reported incident regarding a patient suicide. A review of Patient A?s clinical record was completed on February 22, 2013. The clinical record documented that Patient A was admitted to the facility on January 28, 2013, with diagnoses that included Schizophrenia (a mental condition that causes delusions and hallucinations), and insomnia (inability to sleep). Further review of the patient's care plan for "Psychosis -Disorganized Behavior," dated January 30, 2013, documented that Patient A had a history of "impulsivity as evidenced by threats of self-harm this happens 1-3x week." Patient A?s care plan included the following: "All staff to provide resident (Patient A) with a stable, consistent, and supervised environment in order to assist resident in the stabilization of their psychosis." There were no specific interventions ordered for supervision or focus on the patient as a suicide risk. A review of the Psychological Evaluation for Patient A, dated February 12, 2013, was completed on February 22, 2013. The evaluation indicated that Patient A had a history of "suicidal behavior, jump threat." A review of the "Psychiatrist Assessment Progress Note," dated February 18, 2013, was completed. The note indicated that Patient A had no behaviors and had stated "I hear lots of voices.? The MD ordered an increase in Seroquel (a medication used to treat schizophrenia) on February 19, 2013, in response to the patient hearing voices. During an interview with the facility Administrator on February 22, 2013, at 3:06 PM, the Administrator stated that on February 21, 2013, Patient A was seen by the facility staff at 11:45 AM, entering the facility from the courtyard. At 12:00 PM, lunch was served in the dining room. At approximately 12:50 PM facility staff noticed that Patient A had not picked up his lunch ticket/diet card. The facility staff began to search for Patient A. At 12:50 PM, CNA 4 (Certified Nursing Assistant) and a house keeping staff member found Patient A in his room, inside the unlocked closet, hanging from a sprinkler pipe, with a belt around his neck. The facility staff immediately called 911 and initiated cardio pulmonary resuscitation (CPR). According to the Administrator, Patient A was discovered with a belt around his neck hanging from a pipe that is a part of the facility fire sprinkler system. The Administrator stated that prior to the patient's admission to the facility, Patient A had a history of self-harm attempts, including being on a 72-hour involuntary hold for evaluation in an acute hospital for being a "Danger to Self" due to attempting to jump off of a building. A tour of the facility was conducted on February 22, 2013, at 3:18 PM, with the Administrator In Training (AIT) to include Patient A?s room and the closet where the incident took place on February 21, 2013. It was observed that the closet was a walk-in type closet with a bar for hanging clothes. There was a pipe noted near the ceiling of the closet. The facility maintenance director provided the measurement; the height of the pipe was measured 7' 6" up from the ground. All of the closets in the facility have an exposed pipe in them according to the AIT. It was observed during the tour that the door to the closet had a lock in the doorknob that must be unlocked by staff in order for patients to enter. It was also observed that the door has to be pushed shut completely in order for the lock to engage. It was observed that the door lock showed no physical evidence of tampering. During an interview with the AIT on February 22, 2013, at 3:22 PM, she stated that all the staff will be in-serviced regarding locking the closets to include a demonstration of the process. She stated that staff is expected to open the closet for the patient, stand back a few feet to give them privacy, and then close the door and ensure that the lock has engaged. The AIT stated it has been the facility practice to do it this way. The AIT demonstrated the practice. However, there is no policy and procedures specifically outlining this process or any in-service training on this process. Each employee is trained in the protocol upon being hired. On February 22, 2013, at 3:35 PM, a review was done of the facility document entitled, "Resident Supervision Rounds and Area Safety/Security Rounds," dated February 21, 2013. The form included a list of all patients in the facility by their room numbers, and on the form, staff could document a patients' location every hour on the hour. The document showed that Patient A was seen by staff at 11:00 AM in the "Corridor." The 12:00 PM hour had an entry made that was scribbled out and illegible. During an interview with the Administrator on February 22, 2013, at 4:00 PM, she stated the entry for 12:00 PM of February 21, 2013, was erroneously filled out. The Administrator stated that the staff (CNA 1) had "thought" she saw the patient at 12:00 PM but then realized that she had not seen the patient and scribbled the note out. The Administrator also stated during her interview with CNA 1, who was assigned to Patient A, CNA 1 admitted that she did not go and check on Patient A at 12:00 PM. It is unclear why CNA 1 did not check on the patient. The Administrator stated during the interview on February 22, 2013 at 4:50 PM, that the facility has no policy and procedure for conducting the supervision of residents, every hour on the hour, which is to be documented in the form entitled, "Resident Supervision Rounds and Area Safety/Security Rounds.? She stated that the expected practice is that the staff member assigned the supervision rounds will find each patient and confirm their location each hour. The Administrator stated CNA 1, who was assigned the supervision rounds for Patient A on February 21, 2013, at 12:00 PM, did not locate Patient A. The Administrator stated the facility practice was not followed by CNA1 and Patient A had not been visualized at 12:00 PM. There is no policy or procedure setting forth what to do if someone does not physically confirm a patient?s location. It is unclear why CNA 1 failed to physically locate the patient. The Administrator stated during the interview that all closet keys held by facility staff have been accounted for, including the direct care staff and maintenance/housekeeping staff. The Administrator stated that their investigation showed that Patient A?s closet had not been shut completely and that is how the patient had access to the closet. The Administrator stated that she did not know which staff had last opened the closet door in Patient A?s room on February 21, 2013. There is no written policy and procedure for opening and closing a patient?s closet door. The facility had a protocol to unlock and then close the closet door once the patient was finished. The employees were trained on this protocol during orientation when the employee is hired. During an interview with the Administrator on February 22, 2013, at 4:00 PM, she stated that CNA 1, who was assigned to do rounds on February 21, 2013, at the time of the incident, was put on suspension. CNA 1 was not available for interview. During a telephone interview with the AIT on February 25, 2013, at 4:40 PM, she stated that the procedure for doing rounds every hour and for opening the closets for the residents is not in writing but is a practice that is demonstrated to the staff during orientation. On March 5, 2013, a review was done of the facility resident "Diagnosis Report" dated March 5, 2013. The report showed that all of the facilities 47 residents (current census) have a mental illness with one of the following diagnosis, Schizophrenia (a mental disorder that makes it hard to tell the difference between what is real and not real, marked by delusion or psychosis), Schizoaffective Disorder (a mental condition that causes both a loss of contact with reality (psychosis) and mood problems), or Bipolar Disorder (a mental condition where the person has extreme mood swings including extreme depression and mania). During an interview with the AIT on March 5, 2013, at 11:10 AM, the AIT stated that all of the patients in the facility are in conservatorship or temporary conservatorship, due to either being an extreme danger to themselves, others, or gravely disabled. All of the patients are placed in the facility by the Department of Behavioral Health because they are unsafe to be in the community. On March 5, 2013, at 11:30 AM, a review of the documents entitled, "Resident Supervision Rounds and Area Safety/Security Rounds," ranging in dates from February 7, 2013, through February 21, 2013, was completed. The review revealed 4 instances where there was no documentation of the location of a patient at a specific hour; Patient B was not visualized on February 7, 2013, at 6:00 AM, Patient C and Patient D were not visualized on February 8, 2013, at 7:00 AM, and Patient E was not visualized on February 12, 2013, at 5:00 PM. There was no policy and procedure in place for locating a patient if they were not physically located during the rounds. An interview was conducted with the AIT on March 5, 2013 at 11:55 AM, regarding this issue. The AIT stated that she had no explanation as to why these times were left blank for these patients. It was unclear how often the sheets are reviewed for accuracy. She stated that since the incident they are auditing the rounds daily to ensure that they are being done properly and that all patients are accounted for at all times. There was no policy and procedure in place to review the rounds sheet at the time of the incident. On March 5, 2013, at 11:40 AM, CNA 2 was interviewed. CNA 2 stated that the procedure for rounds is for the staff to go room to room to look for each patient and check that all the closets are locked. If the patient is not in their room she has to go look for them face to face. CNA 2 further stated that she never waits for the patients to come to her; she has to go look for them. She stated that the reason the rounds are done is to ensure that the patients are safe and accounted for. This is a general facility practice. On further interview the CNA stated that when the staff opens the closets for the patients they are to stand there with them the entire time and make sure they do not take anything that is not theirs. The staff then closes the door and checks it to make sure it is locked. CNA 2 stated that the closets need to be kept locked for safety and to ensure that the patients' items are secure and are not taken by other patients. She stated that she learned both procedures upon being oriented to the facility. On March 5, 2013, at 12:12 PM, CNA 3 was interviewed. CNA 3 confirmed the process for doing the rounds is to go room to room to look for the patients and check that all of the closets are locked. CNA 3 stated that if the patients are not in their rooms then she goes to go look for the patient. CNA 3 stated that the reason that the facility does rounds is to ensure that everyone is safe and that they are able to find everyone. The CNA stated that when the staff opens closets for patients that they are to stand with the patient while they get their belongings and then close the door and make sure that it is locked. The CNA further stated that they keep the closets closed and locked for safety and to "keep things from disappearing". She stated that they are trained on these practices when they are oriented and have received in-services on these practices. It is unclear how often staff are trained on the protocols. On March 5, 2013, CNA 4 was interviewed at 12:45 PM. CNA 4 stated that on the day of the incident, she was monitoring the hallway. The lunch started a few minutes late, at about 12:13 PM. At 12:40 PM she asked what patients still needed to get lunch. She was given names and went to go prompt the patients to come for lunch. She prompted the other patients but was unable to find Patient A, so she went to the dining room to see if the patient was there. She checked with the staff in the dining room and the staff informed her they had not seen him (including the staff that had done the 12:00 PM rounds). She went to check the bathroom and the visiting room and when she was unable to find him everyone began a search. CNA 4 stated that she and the housekeeper went to the patient's room to check his closet and found the patient hanging from the pipe with a brown leather belt. She stated that she called a code blue and she and the housekeeper held the patient up to try to loosen the belt. She stated that the Licensed Vocational Nurse (LVN) came in then and they were able to get him down and started CPR. She stated that there were black shoe marks up the wall from the patient's shoes. CNA 4 further stated that they do rounds every hour and must go to look for the patients. She stated that they are trained on this practice when they get oriented and have in-services during the year. During an interview with the Director of Nurses (DON) on March 5, 2013, at 1:00 PM, the DON stated that the focus of the rounds is safety. He further stated that the expectation is for the staff to search for the patient the first minute that the patient is unaccounted for. However, there was no policy and procedure in place at the time of the incident. The facility failed to: Ensure that written policies and procedures were created, approved and implemented by the administration so that a closet with an exposed sprinkler pipe was kept locked per facility protocol. These failures resulted in cause of death of Patient A. 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. |
| 240000682 |
Sky Harbor Care Center |
240012666 |
A |
20-Oct-16 |
HT7412 |
9771 |
REGULATION VIOLATION: 72527(a)(10) Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patient shall have the right: (10) To be free from mental and physical abuse. FINDINGS: The facility violated the above regulation by failing to: Protect two of three sampled patients (Patient A and Patient B) from verbal and physical abuse when the facility was made aware by a certified nursing assistant (CNA 1) who witnessed verbal and physical abuse by certified nursing assistant (CNA 2). This failure resulted in emotional distress for Patients A and B. During an interview with the certified nursing assistant (CNA 1) on January 27, 2016 at 3:05 PM, CNA 1 stated, "Around three weeks ago, the certified nursing assistant [CNA 2] slapped Patient A's hand and stated, 'Stop acting like a damn child.' [CNA 2] then poured a small cup of water on [the] Patient's [Patient A] head." CNA 1 further stated that he immediately reported the physical and verbal abuse of Patient A to the Registered Nurse (RN 1). A review of the declarative statement written by CNA 1 for Patient A, undated, documented the following: "I was working with nursing assistant [CNA 2]. While I was giving care to a patient [unsampled Patient 1], nursing assistant [CNA 2] was giving care to another Patient [Patient A] when patient [Patient A] ripped his brief off in his wheelchair. Nursing assistant [CNA 2] then slapped the patient's [Patient A] hand and said, 'Stop acting like a damn child,' after he slapped his hand, nursing assistant [CNA 2], then poured a small cup of water on [the] patient's [Patient A] head." CNA 1 stated, "[Patient A] was visibly shaken. [Patient A] is blind. [Patient A] panicked." During an interview on January 27, 2016 at 3:49 PM, the Registered Nurse (RN 1) stated that approximately 3 weeks ago a "CNA [CNA 1] alerted myself that he overheard another CNA [CNA 2] verbally abusing another patient [Patient A]. I told him to write it down and I would turn it in to the DON [Director of Nurses]." RN 1 stated that she immediately reported the verbal abuse to the Director of Nurses (DON) that same day. RN 1 does not remember the exact date. RN 1 stated she did not document the incident because, "I am not going to document anything in the chart that I did not see." A review of the declarative statement written by RN 1, dated January 27, 2016, indicated RN 1 documented the following: "I asked the CNA [CNA 1] to write down what had happened and that I would have to let our DON know. Gave DON statement from CNA [CNA 1], [the] DON needed specifics on statement, [I] had CNA [CNA 1] write down specifics and gave statement back to DON." A review of Patient A's clinical records, reflected Patient A was admitted to the facility on September 21, 2015, with diagnoses which included: hypertension (high blood pressure), cerebral vascular accident (stroke in which blood flow is cut off to the brain causing damage) and was legally blind. A review of the history and physical, completed by the physician on September 21, 2015, indicated Patient A had the capacity to understand and make his own decisions. During an interview with Patient A on January 27, 2016 at 4:15 PM, Patient A was observed in bed. Patient A stated, "He [CNA 2] just squirted water on me on my head. He squirted water on people who can't squirt back. Forgive your enemies." Patient A stated, "The water was cold." During a concurrent observation, Patient A was observed to be emotionally upset when discussing the incident with CNA 2, evident by Patient A getting agitated and raising his voice. A review of the Licensed Nurse's Progress Notes for Patient A dated January 1, 2016 through January 27, 2016, indicated there was no documented evidence in the clinical record that: a. An assessment was initiated, b. The physician was notified, c. The responsible party was notified, or d. An investigation was initiated concerning the physical and verbal abuse for Patient A. During an interview on January 27, 2016, at 4:25 PM, the Director of Nurses (DON) stated, "I am completely unaware. I don't remember getting anything about this." 2. During an interview with the Certified Nursing Assistant (CNA 1) on January 27, 2016 at 3:15 PM, he stated, "Around three weeks ago, we [CNA 1 and CNA 2] were transferring Patient [Patient B] into his bed. Once we [CNA 1 and CNA 2] had him [Patient B] lying in bed, CNA [CNA 2] patted [the] patient's [Patient B] stomach and said, 'Hey fatty, how can you live like that? You're f...ing disgusting." CNA 1 further stated that he immediately reported the verbal abuse of Patient B to the Registered Nurse (RN 1). A review of the declarative statement written by CNA 1 for Patient B, undated, documented the following: "We (CNA 1 and CNA 2) were transferring (Patient B) into his bed. Once we had him lying in bed, (CNA 2) patted (Patient B) stomach and said, "Hey fatty, how can you live like that? You're F...ing disgusting." During an interview on January 27, 2016, at 3:49 PM, with RN 1 she stated that approximately 3 weeks ago a "CNA [CNA 1] alerted myself that he overheard another CNA [CNA 2] verbally abusing another patient [Patient B]. I told him [CNA 1] to write it down and I would turn it in to the DON [Director of Nurses]." RN 1 stated that she immediately reported the verbal abuse to the (DON) that same day. RN 1 did not remember the exact date. RN 1 stated she did not document the incident because, "I am not going to document anything in the chart that I did not see." A review of the declarative statement written by RN 1, dated January 27, 2016, indicated RN 1 documented the following: "I asked the CNA [CNA 1] to write down what had happened and that I would have to let our DON [Director of Nurses] know. Gave DON statement from CNA [CNA 1], [the] DON needed specifics on statement, [I] had CNA [CNA 1] write down specifics and gave statement back to DON." A review of Patient B's clinical records reflected Patient B was admitted to the facility on April 18, 2011, with diagnoses which included diabetes (high blood sugar), hypertension (high blood pressure) and Alzheimer's disease (a mental disorder which affects the memory). A review of the history and physical, completed by the physician on June 13, 2015, indicated Patient B did not have the capacity of making decisions. During an interview with Patient B on January 27, 2016 at 4:45 PM, Patient B was observed in bed. Patient B stated, "I do not recall now, but he [CNA 2] did say something. It was not nice. It made me feel uncomfortable." A review of the Licensed Nurse's Progress Notes for Patient B dated January 1, 2016 through 27, 2016, indicated there was no documented evidence in the clinical record that: a. An assessment was initiated, b. The physician was notified, c. The responsible party was notified, or d. An investigation was initiated concerning the verbal abuse for Patient B. A review of CNA 2's employee file on January 28, 2016 at 11:45 AM, documented the date of hire was December 18, 2015. Documentation reflected CNA 2 received abuse prevention training on December 21, 2015. A review of the staffing schedule for December 18, 2015 through January 27, 2016, reflected CNA 2 continued to provide care to Patient A and/or Patient B as follows: a. Both Patients A and B on December 22, 2015, December 23, 2015, December 24, 2015, and December 29, 2015. b. Patient A on December 25, 2015, December 26, 2015, December 27, 2015, January 2, 2016, January 3, 2016, January 10, 2016, January 14, 2016, January 26, 2016, c. Patient B on December 28, 2015, January 1, 2016, January 5, 2016, January 6, 2016, January 7, 2016, January 11, 2016, January 12, 2016, January 13, 2016, January 17, 2016, and January 18, 2016. During a review of the facility's policy and procedure Version 10.27.11, titled "Abuse Prevention and Elder Justice Program," dated 2011, indicated, "This facility recognizes that each patient has the right to be free from all forms of abuse (verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion), mistreatment, neglect, and misappropriate of money or property." Under the section of the policy entitled, "Identification...iii: The employee who firsts suspects or becomes aware of an allegation of abuse, neglect, mistreatment, misappropriation of property, or injury of an unknown source must immediately notify the Administrator, Director of Nurses, or licensed nurse in charge of the resident's care. This is required whether or not the employee believes abuse or other inappropriate conduct occurred...v...In addition, the Director of Nurses is responsible for assuring the immediate measures are taken on behalf of the resident including: 1. Notifying the physician and responsible party... 3. Assessing the resident for physical and emotional injury. 4. Having the physician examine and treat the resident as necessary, 5. Monitoring and documenting the resident's condition and response, and 6. Implementing a plan to protect the resident(s) from harm..." Because the facility failed to protect Patient A and Patient B from verbal and physical abuse when the facility was made aware of the abuse by CNA 1 the patients were placed at risk for further abuse. This violation presented either an imminent danger that death or serious harm would have resulted or a substantiated probability that death or serious physical harm would have resulted. |
| 250000283 |
San Jacinto Healthcare |
250010470 |
A |
20-Feb-14 |
8O2D11 |
6686 |
F 323 42 CFR 483.24 (h) Accidents The facility must ensure that: The patient environment remains as free from accident hazards as possible; and Each patient receives adequate supervision and assistance devices to prevent accident. The facility failed to ensure the safety of Patient A was maintained during a transfer from gurney to bed. During a transfer from gurney to bed, Patient A sustained a right hip fracture on August 30, 2013. The failure to protect Patient A during the transfer resulted in Patient A being admitted to the hospital for right hip surgery.A record review for Patient A was conducted on September 4, 2013. Patient A was re-admitted to the facility on July 17, 2010. Patient A had the following diagnoses: chronic kidney disease, stage IV requiring hemodialysis (medical procedure to remove waste products from the blood), CVA (stroke - with lack of movement to the right side of body), and intellectual disability. Patient A's Minimum Data Set (MDS-a method to evaluate the status of a patient) dated July 22, 2013 indicated, Patient A's cognitive status as "severely impaired" and her mobility (ability to move in bed) and transfer (ability to move from gurney to bed) status as "total dependence" of staff. An interview was conducted with Certified Nursing Assistant 1 (CNA 1) on September 4, 2013, at 10:55 a.m., CNA 1 described Patient A's transfer. CNA 1 and the surveyor viewed Patient A's empty bed as CNA 1 stated, "I did not do any hands on (assist physically with transfer). Patient A, CNA 1 stated," was transferred from gurney to bed by two paramedics and two certified nursing assistants." CNA 1 stated, "Patient A's foot and heel got caught in a gap (space) between the mattress of the gurney and the gurney (metal frame) itself". CNA 1 described Patient A's legs as "frog like" or "diamond shaped" (because of the contractures - reduction of muscle size causing deformity of a joint). CNA 1 stated she heard a "bone crack noise" with the transfer. CNA 1 stated Patient A was previously transferred by the Hoyer Lift (a mechanical electrical powered lift with a sling) to a geri chair (a reclining chair). CNA 1 further stated that the (facility's) Hoyer lift (usually) stayed with the patient. CNA 1 stated,..."if a resident (patient) is transferred in a Hoyer( lift) they have to go back to bed with a Hoyer (lift)." The surveyor asked CNA 1 who was responsible for checking the extremities (arms and legs) of Patient A. CNA 1 stated "we all were...there were three CNAs in the room and two paramedics." CNA 1 further stated that several minutes had passed when she re-checked Patient A and discovered Patient A's right leg bent back in the (opposite direct of frog position). An interview was conducted with CNA 2 on September 4, 2013, at 11:25 a.m., CNA 2 stated, "No Hoyer was used to transfer her (Patient A) back to bed...only a sling (Hoyer lift device without the actual lift) and four workers...two CNAs and two paramedics." CNA 2 further stated if a resident (patient) "get(s) up with a Hoyer they have to go back with a Hoyer..I did not wait for the Hoyer because I was afraid she (Patient A) would pull her dialysis catheter out...usually I wait for the machine." An interview was conducted with CNA 3 on September 17, 2013, at 11 a.m. CNA 3 stated that the day of the incident, August 30, 2013, it was her first day working at the facility and that she did not have training for the Hoyer lift yet by the facility. CNA 3 stated, "Nobody said to use the Hoyer lift...but I know we were supposed to use the Hoyer lift. CNA 3 further stated if a resident (patient) is out of bed with a Hoyer lift then they should go back with a Hoyer lift. CNA 3 was asked about the assistance of the paramedics with Resident 1's transfer, she stated, "Paramedics are not supposed to tell us (CNAs) how to transfer a resident (patient)...the facility is responsible for the resident (patient) because the paramedics are going in and out (of the facility). CNA 3 further stated the "staff and the paramedics transferred the resident (patient) with the sheet only...nobody touched the feet." An observation was conducted of Patient A on September 4, 2013, at 3:15 p.m., at the hospital where she was admitted. Patient A was observed in an ICU (intensive care unit) isolation room (staff and visitors must wear gown and gloves to protect against bacteria). Patient A had contractures (permanent bent/flexion) to the upper and lower extremities, bilateral (both) wrist restraints, a gastric tube (tube in abdomen for liquid nutrition), a dialysis double lumen catheter in her right chest wall, and a right hip dressing. Patient A's lower extremities had a frog-like appearance. Patient A had difficulty communicating. The patient only made grunting and moaning noises and did not say words. A record review was conducted on September 4, 2013, at the hospital where Patient A was admitted. Patient A's "Emergency Room Report" indicated under "Clinical Impression...3. Acute right mid shaft femur fracture." A review of the facility policy and procedure was conducted on September 4, 2013. The policy titled, "Hoyer Lift Usage," indicated, "Do not use Hoyer lift equipment if unfamiliar with the procedure and/or training on use of equipment was not provided." The policy also indicated, "29. return resident (patient) to bed using the same procedure." A review of the company manual of the Hoyer lift product on September 17, 2013 indicated," Do Not lift a patient unless you are trained and competent to do so." During an interview with the Director of Staff Development (DSD) on September 4, 2013, at 15:30 p.m., the DSD stated that CNA 3 did not have one to one training (demonstration) on the Hoyer lift yet. The DSD further stated CNA 3 did not have documented training on the Hoyer lift. When the DSD was asked by the surveyor if Emergency Medical Technicians (EMTs) who transfer patients are given training by the facility for the use of the Hoyer lift, the DSD stated, "No." The DSD further stated, "they (CNAs) are trained that if a patient is removed from bed with a Hoyer device, the patient should go back to bed with a Hoyer lift." The facility failed to ensure Patient A was free from physical injury, by failing to ensure three CNA staff followed protocol for use of a device when transferring Patient A and maintain safe transfer technique when transferring this bed bound patient. Patient A sustained a right hip fracture during the transfer; requiring right hip surgery. 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. |
| 250000283 |
San Jacinto Healthcare |
250010881 |
B |
24-Jul-14 |
DQIE11 |
4541 |
T22 DIV5 CH3 ART3-72311(a)(1)(C) Nursing Service--General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. This RULE: is not met as evidenced by: The facility failed to ensure the care plan for Patient 1, concerning independently smoking, was re-evaluated and updated after Patient 1 had skin cancer surgery on her nose. The facility failed to ensure the care plan concerning Patient 1 independently smoking was re-evaluated and updated after Patient 1 had skin cancer surgery on her nose on January 12, 2012; requiring her to wear a gauze dressing covering her nose and extending to her cheeks and secured to her ears by strings. As a result, the gauze dressing on Patient 1?s face caught on fire on January 19, 2012, while the patient was smoking unsupervised. On January 23, 2012, an unannounced visit was made to investigate an entity reported incident. The record for Patient 1 was reviewed. Patient 1 was admitted to the facility on August 7, 2008. The diagnoses for Patient 1 included basal cell carcinoma (skin cancer) and nicotine dependence (cigarette smoking). On January 12, 2012, Patient 1 had outpatient surgery for nasal (nose) cancer.An order after the surgery on January 12, 2012, indicated to keep the dressing dry and clean and ?do not remove the strings on the cheeks or dressing.? A subsequent physician order, dated January 17, 2012, indicated, ?S/P [status post] SURGERY TO NOSE: APPLY BACITRACIN OINTMENT, PACK WITH XEROFORM GAUZE, COVER WITH DRY DRESSING?? A short-term care plan, dated January 13, 2012, indicated a goal for Patient 1 to be free from infection. The interventions (approach/plan) indicated to keep the dressing dry/clean and to not remove strings on the cheeks or dressing. Smoking safety assessments dated August 2 and December 9, 2011, indicated the facility knew Patient 1 did smoke. A long-term care plan initiated August 2, 2011, indicated generalized interventions (approaches). An update to the care plan on December 9, 2011, indicated a new intervention to encourage Patient 1 to wear a smoking apron. On January 23, 2012, at 3:45 p.m., an interview was conducted with Employee 1. On January 19, 2012, Employee 1 stated that he was inside the facility and saw "a lot of smoke" through the glass door of the patio. Employee 1 saw fire on Patient 1's lap, and it was the blanket. Employee 1 stated he pulled the blanket from Patient 1's lap. Employee 1 stated Patient 1's lap was okay, and then he checked Patient 1's face. Employee 1 stated the gauze was all burned, and Patient 1's eyebrows, forehead, and right eyelashes were burned.On January 23, 2012, at 4:15 p.m., an interview was conducted with Patient 1. Patient 1 had recently had surgery to the nose and had a gauze dressing on her face. Patient 1 stated she had "caught on fire from the lighter." Patient 1 was observed to have multiple red and blister-like burn marks on her face and on her right hand.According to the U. S. National Library of Medicine, National Institutes of Health (?Burns,? updated January 13, 2010), ??.First-degree burns affect only the outer layer of the skin. They cause pain, redness, and swelling. Second-degree (partial thickness) burns affect both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering?. The facility failed to re-evaluate and update Patient 1?s care plan, concerning independently smoking, after she had surgery on her nose for nasal cancer on June 12, 2012. The facility failed to conduct a smoking safety assessment after the January 12, 2012, skin cancer surgery on her nose; when Patient 1 was required to wear a gauze dressing on her nose and cheeks, secured to her ears with strings. The facility failed to assess the potential risks for Patient 1 independently smoking with a gauze dressing on her face.Patient 1 sustained first and second degree burns to the right frontal aspect on her forehead, to the right cheek, and to the right hand. The facility failed to ensure Patient 1?s physician allowed her to smoke, unsupervised, after the nasal surgery required her to wear gauze bandages on her nose. These violations had a direct relationship to the health, safety or security of patients. |
| 250000283 |
San Jacinto Healthcare |
250013294 |
B |
21-Jun-17 |
HDMO11 |
4855 |
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.
Findings:
On April 27, 2017, at 9:52 a.m., an unannounced visit was made to the facility for the investigation of a complaint regarding resident abuse.
Based on interview and record review, it was determined that the facility failed to report to the California Department of Public Health (CDPH) immediately, or within 24 hours, an alleged incident of abuse for one resident (Resident D). Failure to notify the California Department of Public Health (CDPH) had the potential to place Resident D and all facility residents at risk for harm.
A review of Resident D's medical record was conducted. Resident D was a 67 year old female originally admitted to the facility on XXXXXXX 2015, and was re-admitted on January 16, 2017, with diagnoses that included pressure ulcer of sacral region (injury to the skin or underlying tissue usually over a bony area), attention deficit hyperactivity disorder (behavioral disorders such as poor concentration, hyperactivity, and impulsive behavior), major depressive disorder (persistent feeling of sadness), schizoaffective disorder (mental disorder with symptoms that include hallucinations [perception of something not present] or delusions [belief that is not true]), bipolar disorder (mental disorder that can cause extreme shifts in mood), anxiety disorder (mental disorder characterized by feelings of fear and worry), and complications of skin grafts to the legs (surgical operation in which a piece of healthy skin is transplanted to a new site on the body).
Review of a skilled note for Resident D dated February 21, 2017, at 11:17 p.m., indicated, ??Increased anxiety noted, prn Ativan given to decrease anxiety. Res (resident) was noted making false accusations, stated that her wounds are from a CNA (Certified Nurse?s Assistant) beating on her. Res husband (sic) came to visit at 2000 (8:00 p.m.), and Res told her husband the same thing. Res finally calmed down at 2200 (10:00 p.m.). Will cont. (continue) to monitor Res for any changes??
Further review of Resident D?s facility record found no documentation that indicated the allegation of abuse had been reported to the facility?s abuse coordinator or CDPH, or that the allegation of abuse had been investigated.
On April 28, 2017, at 1:27 p.m., a phone interview was conducted with the facility Administrator (AD). The AD said he was the abuse coordinator for the facility. The AD was asked if the allegation of abuse had been reported to him. The AD stated that it had not been reported to him. The AD was then asked if all allegations of abuse were supposed to be reported to him. The AD stated, "They should be, yes." The AD further stated all allegations were to be reported to him to investigate, to validate, substantiate, or unsubstantiate. The AD was asked if all allegations of abuse were to be investigated. The AD stated, "Yes."
On April 28, 2017, at 2:17 p.m., a phone interview was conducted with the Director of Nursing (DON). The DON was asked if the allegation of abuse should have been reported to the AD given he was the abuse coordinator for the facility. The DON stated, "Yes, definitely." The DON stated that all allegations were supposed to be reported to the AD.
On April 28, 2017, at 3:00 p.m., a phone interview was conducted with the licensed vocational nurse (LVN) who had documented the allegation of abuse. The LVN stated one night Resident D had alleged someone had injured her legs. The LVN stated that the resident had been unable to name who had allegedly abused her. The LVN further stated that she had known that the injuries were caused by failed skin grafts and not by a facility staff member. The LVN stated she "guessed her mistake" was that she had not informed the AD about the allegation. The LVN further stated she knew the resident "was lying."
Review of the facility?s policy titled, ?Resident/Staff/Family Abuse Reporting,? dated February 16, 2017, indicated, ??1. Any person(s) witnessing or having knowledge of potential or actual abuse must report the incident to the Administrator and or/designee immediately?3. The report is to be submitted to the Administrator or designee within 24 hours for further investigation??
Therefore, the facility staff failed to report an allegation of abuse to the abuse coordinator for investigation and the allegation was not reported to CDPH within 24 hours.
The failure of the facility to report the alleged abuse placed all residents at the facility in potential danger to their health, safety, and security. |
| 910000077 |
SEACREST CONVALESCENT HOSPITAL |
910009559 |
B |
13-Nov-12 |
E7CT11 |
7745 |
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 psychosocial well-being, in accordance with the comprehensive assessment and plan of care.The facility failed to ensure Resident A, who had decreased mobility and a history of colon cancer, was assessed and monitored for amount and consistency of bowel movement (BM) as indicated in the plan of care to prevent fecal impaction (the formation of a large mass of hard stool in the rectum). On June 14, 2012, at 12 p.m., Resident A vomited undigested food and had fluctuating low oxygen saturation of 80 to 91 percent [oxygen saturation is the percentage of oxygen in the blood - the normal range is 95 to 100 percent (%)]. The physician was notified and Resident A was transferred to a general acute care hospital (GACH) by paramedics at 3:25 p.m., admitted, and was diagnosed with acute fecal impaction. On June 21, 2012, at 8 a.m., an unannounced visit was made to the facility to investigate a complaint received in the Department on June 18, 2012, that Resident A was not continuously assessed for bowel motility (moving) and/or need of medication to promote bowel motility and prevent constipation.According to the admission record, Resident A was admitted from a psychiatric hospital on June 6, 2012, with diagnoses that included gastrointestinal (GI) cancer, history of bowel resection [(a surgical procedure in which a part of the large or small intestine is removed) performed in about 2000], generalized weakness, and dementia (progressive deterioration of intellectual capacity).The Minimum Data Set, an assessment care screening tool, dated June 12, 2012, indicated the resident was moderately impaired in her cognitive skills for daily decision-making, required extensive assistance from staff with activities of daily living and was totally dependent for toilet use. The resident was assessed as frequently incontinent (loss of control) of bowel.Resident A had a physician's order dated June 6, 2012, for Mira lax (laxative)17 grams at bedtime and Colace (stool softener) 250 milligrams twice daily for bowel management.A plan of care dated June 6, 2012, for prone to constipation related to decline in mobility and history of GI cancer, status post resection, indicated the goal was for the resident to have a BM every three days. The approaches included to monitor BM (stool) for amount and consistency, monitor the effectiveness of medication and notify the physician accordingly. A review of the Medication Administration Record (MAR) from June 6 to 14, 2012, indicated the licensed nurses documented " Y " (yes) indicating the resident had a BM and " N " (no) indicating the resident did not have a BM. The monitoring documentation did not include the amount and consistency of the resident's BM in order to assess the effectiveness of the laxative. A review of the certified nurse assistant (CNA) Daily Documentation from June 6 to 14, 2012, revealed the CNAs documented ?Y? (yes) or ?N? (no) for BM every shift. The documentation reflected the resident had a BM daily, and at times twice a day. However, there was no documentation as to the amount of stool (large, medium, or small) or the consistency of stool (hard, soft, formed, ribbon-like, watery) to identify if the resident was emptying her bowel completely, as indicated in the plan of care. The Daily Licensed Nurses note dated June 11, 2012, for the 7 a.m. to 3 p.m. shift, indicated the resident complained of mild to moderate lower abdominal pain, and the pain scale level was 5 (on a scale of 1 to 10, with 10 being the worst pain). The note indicated Tylenol was given and it was effective. There was no documentation as to why the resident was complaining of abdominal pain and no documentation that the resident was checked for fecal impaction. Also, there was no documentation the physician was notified that the resident was complaining of abdominal pain, in accordance with the plan of care. Further review of the Daily Licensed notes from June 11 to 14, 2012, revealed in the bowel incontinent section, a box was checked for abdomen-soft and non-tender with normal active bowel sounds in all quadrants. There was no other documentation aside from the check marked in the box.On June 14, 2012, at 12 p.m. the Licensed Nurses Notes indicated the resident appeared weak, and vomited a large amount of undigested food. The note indicated Resident A's oxygen saturation was fluctuating between 80 to 86 % while receiving 3 liters per minute (L/min) of oxygen (O2). There was no documentation the resident's abdomen was assessed nor the resident was checked for fecal impaction. The physician was notified with orders to continue to monitor the resident. The Licensed Nurses Notes on the same date at 1 p.m., indicated Resident A's O2 saturation was 87 and 90 %, while receiving (increased O2) at 10 liters per minute, and she was complaining of vaginal pain of 4 out of 10 (0 is no pain and 10 is severe pain).Tylenol 325 milligram, 2 tablets, were given without relief. At 3:05 p.m., the resident was receiving 10 L/min. of oxygen and her O2 saturation reading was 80 to 84 %, the resident continued to complain of vaginal pain, and was transferred by paramedics to the GACH at 3:25 p.m.A review of the Emergency Department Admission Note dated June 14, 2012, obtained from GACH revealed the resident had evidence of fecal impaction with hard stool at the rectal vault (the opening). The resident was disimpacted (manual removal of hard stool) and admitted to the GACH with diagnosis of acute fecal impaction.During an interview and record review on June 21, 2012 at 8:40 a.m., with the Certified Nurse Assistant (CNA 1), she said she took care of Resident A every day she worked. A review of the Nurses Aides Notes from June 7 through 14, 2012, CNA 1 documented the resident had a BM on June 7, 10, 11, 12, and 13, 2012. Further interview revealed the resident wore an incontinent pad. CNA 1 stated she assisted the resident to the bathroom, but the resident did not have a formed BM, only smears of stool on the incontinent pad for June 7, 10, 11, 12, and 13, 2012. However CNA 1 documented the smear as a BM on the Nurses Aides Notes and did not report the BM results (smear) to the licensed staff. During an interview with a licensed vocational nurse (LVN) on June 22, 2012 at 9 a.m., she said the facility's policy is to record the number of stools, record if the stool has a foul odor, or if it is a diarrhea stool. She was not able to explain the assessment method used by the facility to monitor a BM for amount or consistency as described in the plan of care. The facility's policy and procedure revised December 2011, titled ?Bowel Monitoring " indicated the CNA was to record if the resident had a bowel movement or no bowel movement by charting "Yes" for a BM or , "No" for no BM. If the resident had no BM for two days, the CNA was to report this condition to the charge nurse for proper intervention. The CNA failed to record the BM accurately and report to the licensed nurse. The facility failed to ensure Resident A, who had decreased mobility and a history of colon cancer, was assessed and monitored for amount and consistency of bowel movement as indicated in the plan of care to prevent fecal impaction. On June 14, 2012, at 12 p.m., Resident A vomited undigested food and had fluctuating low oxygen saturation of 80 to 91 percent. The physician was notified and Resident A was transferred to a GACH where she was admitted and diagnosed with acute fecal impaction. The above violation had a direct relationship to the health, safety, and security of Resident A. |
| 910000074 |
SANTA MONICA HEALTH CARE CENTER |
910009748 |
B |
14-Feb-13 |
RX6L11 |
3550 |
CFR 483.70(c)(2) - F456 The facility must maintain all essential mechanical, electrical, and patient care equipment in safe operating condition.On January 17, 2013, at 11:10 a.m., an unannounced visit was made to the facility to investigate a complaint regarding no change in work status for water heaters that had been in project since April 26, 2011.Based on observation, interview and record review, the facility failed to maintain all essential mechanical equipment in safe operating condition by not complying with the requirements from OSHPD (Office of Statewide Health Planning and Development), the authority having jurisdiction for alteration and construction work in healthcare facilities, for the installation and use of two gas-fueled water heaters designated for all residents in the facility.During a tour of the facility on January 17, 2013, 11:20 a.m. to 11:45 a.m., the Evaluator in the presence of Employee A and the OSHPD area compliance officer (ACO), observed two gas-fueled water heaters connected to the building water supply used for residents, and an additional water heater that was not connected in the basement. As pointed out by the OSHPD ACO, the water heaters were not ventilated properly, had improperly secured pipes, had inadequate temperature regulating devices, and no insulation for the water pipes. The basement that contained the water heaters was located directly under the residents? floor.According to a field visit report dated January 14, 2013, from the OSHPD ACO, the following concerns were identified and not corrected by the facility: 1. There was no change in the temporary location of the water heaters since changed as an emergency on May 18, 2011. 2. There had been no work progress since May 18, 2011. The contractor or the facility had delivered an additional water heater which was not part of the approved plans. The items that were listed on an open report dated May 18, 2011, had not been cleared to date as of January 14, 2013. 3. The ventilation did not appear to be adequate. 4. The pipes were not supported and were missing insulation. 5. The temperature regulating devices were not adequate.During an interview with the OSHPD ACO at the time of the observation, she stated that to this date, January 17, 2013, all the items listed on the report dated January 14, 2013, had no change in work status. She stated that she had visited the facility at least every three months since 2011, with no change in work status.During an interview with Employee A at the time of the observation, she stated that she had been the administrator since January 2012, and had been aware of the ongoing issues with the water heater project. She could not explain why the work had not been completed. Employee A stated she would communicate OSHPD?s concerns to the corporate office but for one reason or another, the work would not progress. There was no documented evidence that could be provided to provide reasonable explanations why the project had not been completed for almost two years.The facility failed to maintain all essential mechanical equipment in safe operating condition by not complying with the requirements from Office of Statewide Health Planning and Development (OSHPD), the authority having jurisdiction for alteration and construction work in healthcare facilities, for the installation and use of two gas-fueled water heaters designated for all residents in the facility. These violations had a direct relationship to the health, safety, and security of all patients of the facility. |
| 970000043 |
ST. JOHN OF GOD RETIREMENT AND CARE CENTER |
910009825 |
A |
19-Apr-13 |
913811 |
10540 |
?72311(a) (2) Nursing Services-General Nursing service shall include, but not limited to the following: (2) Implementing each patient?s care plan according to the methods indicated. Each patient?s care shall be based on this plan. ?72523(a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On January 12, 2010, the Department received an entity reported incident letter that indicated that Patient 1 fell in the bathroom on January 11, 2010, at 7:15 a.m., resulting in a fracture of the left hip.On January 28, 2010, at 8 a.m., an unannounced investigation was conducted at the facility. Based on observation, interview, and record review, the facility failed to implement Patient 1?s care plan and follow the facility?s policy and procedure by failing to: 1. Investigate a prior fall which occurred in March 2009 to identify specific patterns, situations, and behaviors associated with the fall incident, to prevent future falls, as stipulated in the facility?s policy and procedure. 2. Supervise, assist, and closely monitor Patient 1 while the patient was using the toilet, according to the patient?s plan of care. These failures resulted in Patient 1 falling and sustaining a left hip fracture, being transferred to a general acute care hospital (GACH), and undergoing open reduction internal fixation [(ORIF) surgical procedure to set bones with fixation of screws and/or plates to enable or facilitate bone fracture healing] of a left hip fracture. On January 28, 2010, at 8:05 a.m., Patient 1 was observed awake, lying in her bed. During an interview with Patient 1 at that time regarding her fall, she stated she got up to use the restroom barefooted. She stated the restroom floor was ?slippery? and her foot slipped while she bathed herself and she fell to the floor. Upon inspection of the bathroom at that time, the floor was tiled. A review of the Admission Face Sheet indicated Patient 1 was a 95 year-old female, originally admitted to the facility on December 14, 2006, and readmitted on January 15, 2010. The patient?s readmission diagnoses included muscle weakness, gait disturbance, osteoporosis (thinning of bone tissue and loss of bone density), a left intertrochanteric fracture (a hip fracture where the upper part of the thigh bone is fractured), and status post open reduction and internal fixation. A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated December 17, 2009, indicated Patient 1 was independent with cognitive skills for daily decision making, had no long- term memory problems and was able to make herself understood and understand others. The MDS indicated Patient 1 required limited assistance with dressing, personal hygiene, and bathing, was continent (has control) of the bladder and bowel functions and required supervision and oversight for toilet use. Also, according to the MDS, Patient 1 had unsteady balance while standing. Upon further review, the quarterly MDS, dated June 18, 2009, indicated Patient 1 had a fall within the past 31 to 180 days (March 24, 2009).According to the status-post fall care plan, dated March 24, 2009, the staff?s plan of action was to monitor the patient closely and keep her visible. Another care plan to prevent fractures secondary to osteoporosis, dated December 17, 2009, indicated Patient 1 would be provided the necessary assistance with activities of daily living, which included toilet use, and would be visibly observed to reduce the risk of falls and injury. These care plans were not implemented when nursing staff failed to provide assistance with toileting and the patient was not visible to the assigned certified nursing assistant (CNA 1) when left unattended in the bathroom. On January 28, 2010, at 8:35 a.m., during an interview CNA 1 stated she was the person who found Patient 1 on the floor after the fall. CNA 1 stated the morning of the fall she helped Patient 1 to the toilet, which was the patient?s usual routine. CNA 1 stated she helped the patient sit on the toilet and then left the patient unattended. CNA 1 stated she heard a thump in the bathroom and when she went to check on the noise, she found the patient on the floor with her back resting against the wall next to the bathroom door. CNA 1 stated she notified the charge nurse and she helped the patient to the bed. CNA 1 stated the patient reported pain to her left arm, but did not report any pain to her hips. CNA 1 stated the patient was wearing tennis shoes and the bathroom floor was dry. CNA 1 also stated she believed it was the first time Patient 1 fell and she was not sure if the patient had fallen in the past.On January 28, 2010, at 8:55 a.m., during an interview regarding Patient 1?s fall, a licensed vocational nurse (LVN 1) stated she saw Patient 1 on the floor next to the toilet when she walked into the bathroom. LVN 1 stated she checked for any spills on the bathroom floor because Patient 1 had verbalized to her that she had slipped, but LVN 1 stated she did not find any spills. According to LVN 1, the patient was not barefoot but LVN 1 could not remember what type of footwear the patient was wearing at that time. LVN 1 stated the patient got up off the floor and walked over and sat on her chair. LVN 1 stated the patient reported shoulder pain, but when the patient reported pain to her left knee, x-rays were taken. LVN 1 also stated she could not recall if the patient had a previous fall.On January 28, 2010, at 9:15 a.m., during an interview the registered nurse (RN 1) supervisor stated she assessed Patient 1 after the fall. RN 1 stated the patient had an unsteady gait when she stood up to walk. RN 1 stated she notified the patient?s physician of the incident and the assessment findings. A review of the facility?s investigative report, dated January 12, 2010, indicated Patient 1 stated she went to the bathroom to use the toilet and when she tried to sit on the toilet, she slipped and fell to the floor. The investigative report did not include recommendations on how to protect the patient from further injury. On January 28, 2010, at 2:20 p.m., during an interview with the director of nursing (DON) regarding the fall on January 11, 2010, she stated she assessed the area for environmental factors that could have contributed to the patient?s fall but did not include this in her investigative report. According to the DON, based upon the circumstances, Patient 1 should have been supervised while using the toilet and not left unattended.On January 28, 2010, at 2:25 p.m., the DON stated there was no investigation conducted for Patient 1?s unwitnessed fall that occurred on March 24, 2009. The DON stated she could not find an investigation. The DON also stated she did not investigate whether Patient 1 had a history of falls because she focused only on the current fall. The DON stated she did not verify what interventions were indicated after the first fall incident.According to the facility?s policy and procedure titled, ?Accident/Incident Reporting, Investigation, Protocol of,? dated April 2004, the DON would conduct an investigation of all incidents involving injury to a patient. This investigation was to be documented on the Accident Investigation Form. The investigation should include an environmental and equipment assessment and a recommendation on how to protect the resident from further injury, which the DON failed to follow.A review of a Nursing Progress Note form dated January 11, 2010, at 7:15 a.m., indicated Patient 1 was found on the floor in a sitting position. According to the Nursing Progress Note, the patient stated she slipped while sitting on the toilet. An entry timed at 9 a.m., indicated the patient reported feeling pain to her left shoulder, left knee, and left hip. The Nursing Progress Note indicated that at 9:45 a.m. the patient?s physician ordered a ?STAT? (immediately) x-ray of the patient?s painful body areas. The Nursing Progress Note dated January 11, 2010, at 2:15 p.m., indicated the facility?s staff assisted Patient 1 to stand as directed by the patient?s physician. According to the Nursing Progress Note, the patient was ?wobbly? and had an unsteady gait. The patient reported pain to her left arm and left leg while standing.A review of an x-ray report, dated January 11, 2010, at 1:04 p.m., indicated Patient 1 had a suspected fracture of the left femoral trochanter (part of the leg bone closest to the hip). Another x-ray report, dated January 11, 2010, at 4:28 a.m., indicating a possible non-displaced intertrochanteric fracture and recommending a computer tomography (CT) scan for a definitive diagnosis. A review of a Nursing Progress Note, dated January 12, 2010, for the 11 p.m. to 7 a.m. shift, indicated Patient 1 reported pain to her left shoulder and left hip and was medicated with pain relief medication. At 6:15 a.m., on January 12, 2010, the patient left the facility via ambulance to the GACH as per the physician?s order for a CT scan evaluation of a possible fracture. A review of the GACH?s ?Medical Imaging Report? dated January 12, 2010, indicated Patient 1 had a left femoral intertrochanteric fracture (left hip). A GACH Progress Record note dated January 13, 2010, indicated Patient 1 underwent spinal anesthesia (needle inserted through spinal cord space to numb surgery site) and an ORIF surgery was performed to repair the patient?s left fractured hip. According to the facility?s policy and procedure titled, ?Fall Prevention Program? dated April 2004, the facility?s staff would identify specific patterns, situations, and behaviors associated with a fall incident to prevent future falls. However, the facility?s staff did not fully investigate the circumstances of the first fall and implement the plan of care to prevent future falls.The facility failed to implement Patient 1?s care plan and follow the facility?s policy and procedure by failing to: 1. Investigate a prior fall which occurred in March 2009 to identify specific patterns, situations, and behaviors associated with the fall incident, to prevent future falls, as stipulated in the facility?s policy and procedure. 2. Supervise, assist, and closely monitor Patient 1 while the patient was using the toilet, according to the patient?s plan of care. The above violations either jointly, separately, or in combination of, presented a substantial probability that death or serious physical harm would result to Patient 1. |
| 910000084 |
SUNNYSIDE NURSING CENTER |
910009864 |
B |
01-May-13 |
4DG011 |
6960 |
Title 22 Section 72315 (b) Nursing Service ? Patient Care Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. On August 18, 2010, the Department of Public Health received an Entity Reported Incident (ERI) reporting that a patient alleged a facility staff would not let her go to the bathroom, locked the door, and hit her in the mouth with a closed fist. Based on observation, interview, and record review, the facility failed to ensure Patient 1 was free from abuse of any kind. Patient 1 was hit by a certified nursing assistant (CNA 4), and received a laceration to her bottom lip that had bleeding. A review of the medical record indicated Patient 1 was readmitted to the facility on December 11, 2008, with diagnoses including dementia (loss of mental function) without behaviors and psychosis (an abnormal mental condition). The Minimum Data Set (MDS), an assessment and care screening tool, dated May 17, 2010, indicated Patient 1 had moderately impaired cognitive skills for daily decision making, however, she was usually able to make herself understood. The MDS indicated Patient 1 was occasionally incontinent of bowel function and frequently incontinent of bladder function and required extensive assistance from the staff with her toileting needs. A review of her care plans revised May 17, 2010, addressed Patient 1's use of antipsychotic medication manifested by striking out, constant yelling, resistance to care, and restlessness/constant body movement, and for her cognitive impairment. The nursing interventions on both care plans included maintaining a calm and less stressful environment for the patient, maintaining the patient's safety, and maintaining the patient's respect and dignity. There was no indication in the care plans that Patient 1 had a tendency to lie, tell stories or make accusations, or that she had self-injury tendencies. On August 20, 2010, a review of the facility?s abuse investigation notes regarding the allegation that occurred on August 18, 2010, was conducted.According to the notes, Patient 1 was interviewed and stated that she needed to use the restroom, so she asked CNA 4 if she could go, and was told no. CNA 4 then closed and locked the bathroom door, and came back and struck her in the face. Patient 1 gave a description of the CNA and was able to identify her on sight. Patient 1's description of the alleged events were told to different CNAs, a licensed nurse (LVN 10) and the administrator at separate times on the day of the alleged incident. It was indicated Patient 1 was consistent in her description of the events occurring on the day of the alleged abuse.During an interview with Patient 1 on August 20, 2010, she was again consistent while describing the events of the alleged abuse incident. According to the Charge Nurse Evaluation dated August 18, 2010, at 11:18 am Patient 1 was observed by CNA 7 in her room doorway with a small amount of blood on her lower lip. It was indicated the charge nurse overheard Patient 1 tell CNA 7 "A lady hit me in the mouth because I tried to go to the bathroom.? The charge nurse conducted a complete check of the patient's oral cavity and observed an abrasion on the mid lower lip with a small amount of bright red blood on it. It was indicated, while at the nursing station, Patient 1 repeated she was not allowed to go to the bathroom and was hit in the mouth (demonstrating with a closed fist). A review of the Complaint/Grievance form dated August 18, 2010, indicated Patient 1 described the alleged incident of a lady hitting her in the mouth. It was documented that CNA 7 saw blood on the patient's lip and reported it to the charge nurse. The notes indicated Patient 1 told the staff no one should be treated that way and she was concerned for her safety. The summary portion of the investigation indicated Patient 1 was able to describe the CNA and the patient was consistent with retelling the events of the incident. A review of the administrator?s investigation dated August 18, 2010, indicated Patient 1 was able to describe the alleged perpetrator prior to a visual identification process.During the initial identification process, Patient 1 identified the suspected CNA and stated "I think it was her.? When asked for clarification, Patient 1 stated "Yes, she did it", referring to the same CNA. A second visual identification was conducted with another group of employees, including CNA 4. Patient 1 again identified CNA 4 and stated, "She did it.?On August 20, 2010, at 1:40 pm, the administrator stated Patient 1 was consistent with her description of the abuse incident, and never changed her story. He stated Patient 1 described the alleged abuser and then visually identified her on sight. On August 20, 2010, at 2 pm, during an interview regarding the incident, LVN 10 stated she saw fresh bright red blood trickling down Patient 1's bottom lip. When asked what happened, the patient demonstrated with a closed fist as if she were hit in an upward motion. LVN 10 stated she saw an abrasion that looked to be caused by the patient's top teeth hitting her bottom lip. LVN 10 stated Patient 1told her CNA 4 locked the bathroom door and would not let her go to the bathroom. LVN 10 had CNA 7 check the bathroom door, and it was locked. LVN 10 stated Patient 1 was usually anxious, would yell, scream and verbalize repetitive concerns, however, she had never accused anyone of abuse. According to LVN 10, Patient 1 did not have the behavior of telling lies or making up stories.On August 20, 2010, at 3:45 pm, during and interview Patient 1 stated CNA 4 had taken care of her before and was ?mean,? but had never hit her. Patient 1 could not explain what she meant by mean. She stated it hurt when the nurse hit her and she could not see the blood, but she could taste it.At the time of the investigation, there were no other alert and oriented patients on the unit that could be interviewed in regards to the care provided by CNA 4. During the course of the investigation, CNA 4 was not available for an interview. A review of a follow up investigation dated August 25, 2010, indicated CNA 4 was reassigned to another nursing station, working with predominantly alert and oriented patients where she would be closely monitored. A review of CNA 4's employee file indicated a Notice/Record of Warning to the Employee had been issued on December 3, 2009. The content of the warning addressed the employee?s failure to provide morning care and toileting needs to a patient, leaving the patient soiled and wearing dirty clothes.The facility failed to ensure Patient 1 was free from abuse of any kind. Patient 1 was hit by a certified nursing assistant (CNA 4), and received a laceration to her bottom lip that had bleeding. The above violation had a direct relationship to health, safety, or security of Patient 1, and any other patient in the facility. |
| 910000330 |
SHARON CARE CENTER |
910010099 |
A |
20-Aug-13 |
P9JD11 |
11034 |
F309483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The Department received a telephone complaint on April 14, 2011, alleging a resident (Resident 1) had a femur fracture requiring placement of a soft leg cast (immobilizer), which the facility took off, resulting in poor positioning and dislocation of the resident?s hip. On May 6, 2011, at 6 a.m., an unannounced complaint investigation was conducted. Based on interview and record review, the facility failed to: Follow physician?s orders and Resident 1?s plan of care in maintaining an abduction pillow (a medical pillow used to immobilize a person's legs just after hip surgery) and left leg immobilizer in place for several days (March 24-26, 2011). This failure resulted in Resident 1, who had a recent history of a left hip dislocated fracture with repair, receiving a left hip mal-alignment and dislocation causing much pain. He was admitted to a general acute care hospital (GACH) for nine days, requiring strong pain medication [Dilaudid .5 mg/intravenous (IV)], hip surgery, and blood transfusions. On May 5, 2011, at 2 p.m., during a telephone interview, Resident 1?s family member stated the resident had a physician?s order to keep the splints on and in place after surgery. The family member stated, during a visit, on March 26, 2011, the resident was without the leg immobilizer and the abduction pillow in place and the resident was found in the dark, with the privacy curtains pulled, complaining of pain. The family member stated a certified nursing attendant (CNA 1) came in the room and attempted to pull the resident?s left leg straight, but was unable. The family member stated she called the physician and informed him that the resident had been without the splint (abductor pillow) and was complaining of severe pain. The physician stated the resident would be transferred immediately to the hospital with the possible need for another surgery.A review of Resident 1?s clinical records on May 6, 2011, indicated the resident was a 74 year-old male who was admitted to the facility on March 13, 2011,with diagnoses of dementia (loss of brain function that occurs with certain diseases), hypertension (high blood pressure) and chronic airway obstruction (the upper or lower airway is chronically obstructed). According to the history in the clinical record, the resident had a recent admission to the GACH on March 3, 2011, for a left hip arthroplasty (surgery reconstructing a joint) and a recent closed reduction (treating fractures without opening the skin) of the left hip with a percutaneous abductor tenotomy (surgical repair of a tendon [attaches a muscle to a bone]).A Minimum Data Set (MDS), a standardized assessment and care screening tool, dated March 23, 2011, indicated Resident 1 had the ability sometimes to make his needs known, but rarely understood others. The resident had both long and short-term memory problems. According to the MDS, Resident 1 was non-ambulatory and required the assistance of two persons with transfers and extensive assistance for all other activities of daily living.A review of a ?Nursing Admission and Assessment? form revealed Resident 1 was admitted to the facility with a left lower leg immobilizer on March 13, 2011. A review of a physician?s order, dated March 14, 2011, indicated the resident was to have an abductor pillow in place and a left lower extremity (LLE) immobilizer while in bed. A review of a short-term care plan, dated March 14, 2011, indicated the resident was at risk for injury secondary to status-post left closed hip reduction/left hip fracture repair. The staff approaches included visual checks, safety using hip precautions, abductor pillow, and placing the bilateral lower extremity (BLE) in proper alignment while maintaining the left knee immobilizer in place. A review of the daily ? Licensed Notes? from March 13-23, 2011, indicated there was no documented evidence the resident?s abductor pillow or LLE immobilizer were in place as prescribed by the physician. A review of a physical therapist (PT) note, dated March 24, 2011, indicated the resident was found in bed in a supine position (lying face up) without the abductor pillow and leg immobilizer intact. According to the PT assessment and note, the resident?s left hip was in a flexion (the joint angle decreasing), abduction and rotation position (motion that pulls a structure part away from the midline of the body/ a motion that occurs when a part turns on its axis), while complaining of left hip pain with restlessness and agitation. The PT indicated the charge nurse was notified. A review of a Licensed Nursing Note, dated March 24, 2011, (3-11 p.m. shift), indicated the resident was found in bed without the immobilizer or pillow with his legs flexed moaning. The note indicated the resident?s physician was called and informed of the incident at 4 p.m., and pain medication was given. The physician ordered x-rays of the bilateral hips and pelvis. A review of the x-ray report for the pelvis/hip/upper thigh, dated March 25, 2011, indicated there was mild lateral subluxation (partial dislocation) of the prosthetic (a device, either external or implanted, that substitutes for or supplements a missing or defective part of the body) femoral head (highest part of the thigh bone [femur]). A review of the Medication Administration Record (MAR), for the month of March 2011, indicated the resident received Tylenol 650 milligram for pain on March 25, 2011, at 11 a.m., and twice on March 26, 2011 at 7 a.m., and 1 p.m., after the left hip was identified dislocated. A review of a physician?s order, dated March 26, 2011, and timed at 7:45 p.m., indicated to transfer the resident to the GACH for evaluation of the left lower extremity pain. Resident 1 left the facility at 7:55 p.m. On May 6, 2011, at 9:30 a.m., during an interview, the facility?s director of nurses (DON) stated an abductor pillow and the brace were ordered to keep Resident 1 from rotating his hip. The DON stated the abductor pillow and brace were noted off by the dayshift nurse the morning of March 24, 2011. The DON stated it was left off until March 26, 2011, because they could not put it back on. The DON stated the physician was notified and x-rays were ordered and taken, but had to be retaken because the first set was not readable. The DON stated the resident had an appointment to see the orthopedic surgeon (a physician who specializes in the diagnosis, preoperative, operative, and postoperative treatment of diseases and injuries of the musculoskeletal [bones/muscle] system) on March 28, 2011. The DON stated the resident was complaining of much pain while the family was at the bedside, so the resident?s primary physician was notified and gave an order to transfer Resident 1 to the GACH immediately. On May 6, 2011, at 11:30 a.m., the physical therapist assistant (PTA) stated an abductor pillow keeps the resident?s legs separated and the knee immobilizer prevents the knee and hip from being in a flexed position. He stated he saw the resident around 4 p.m., on March 24, 2011, with the abductor pillow and knee immobilizer off. The PTA stated the resident?s left knee was in a flexed position. The PTA stated, ?I realized something was wrong, because the resident?s legs should not be in that position.? The PTA stated he notified both the nurse and his supervisor that the resident was complaining of pain with a dislocation of his left hip. The certified nursing assistant (CNA 1) stated on May 6, 2011, at 12 p.m., ?I saw the pillow (March 24, 2011) was not on the resident and I tried to position him and place the pillow back in place, but he was combative and I could not do it.? When CNA 1 was asked if she reported her findings to the nurse, she stated, ?I was supposed to report it to the charge nurse, but I did not, because I thought the PT would come and place the pillow back.? On May 28, 2013, at 12:30 p.m., during a subsequent telephone interview, Resident 1?s family member stated when she visited Resident 1 on March 26, 2011, he was in pain, moaning with facial grimacing without the leg immobilizer and abduction pillow in place. The family member stated she wanted to immediately call an ambulance, but the facility staff told her she could not call an ambulance. The family member stated she called the resident?s physician instead and he told her to get the resident to the emergency room (ER) immediately. The family member stated after the resident was transferred to the GACH, the physician had to take the resident to surgery and replace the entire left hip with screws. A review of the GACH?s records on May 31, 2013, indicated Resident 1 was seen in the ER on March 26, 2011, at 8:52 p.m., with the chief complaint of left hip pain with dislocation. According to the documented history and physical (H/P), the resident had hip pain for three days while in the skilled nursing facility (SNF) and was holding the left hip in a flexed, internally rotated position. The note also indicated the family member, who was in the ER, stated the SNF had taken X-rays of the resident?s hip a couple of days prior, but did not tell her why. The ER physician documented the resident yelled and complained of a significant amount of pain when attempts were made to straighten his left leg, which required Dilaudid IV for pain. The pelvis x-ray indicated the resident had a cephalad dislocation (dislocation toward the head (femoral) or anterior section) of the left hip prosthesis.An Operative Note, dated March 29, 2011, indicated the resident underwent a total left hip revision, after being placed under general anesthesia, with three screws used to secure the acetabulum (concave surface of the pelvis). During the procedure the resident received two units of fresh frozen plasma (liquid portion of human blood that has been frozen and preserved, which contains the coagulation properties; to assist in clotting blood) and three units of packed red blood cells (RBC, also called erythrocytes). The GACH?s Discharge Summary indicated the resident was discharged to another SNF on April 4, 2011. The facility failed to: Follow the physician?s orders and Resident 1?s plan of care in maintaining an abduction pillow and a left leg immobilizer in place for several days (March 24-26, 2011). This resulted in Resident 1, who had a recent history of a left hip dislocated fracture with repair, receiving a left hip mal-alignment and dislocation causing much pain. He was admitted to a GACH for nine days, requiring strong pain medication, hip surgery, and blood transfusions. The above violation presented either an imminent danger that death or serious harm would result to Resident 1 or a substantial probability that death or serious physical harm would and did result to Resident 1. |
| 970000017 |
SUNNY VIEW CARE CENTER |
910010201 |
A |
21-Oct-13 |
4PX711 |
9388 |
F323 CFR 483.25(h) Accidents The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On June 12, 2013, an unannounced visit was made to the facility to investigate an entity reported incident (ERI) regarding Resident 1, who was dropped about two inches from the Invacare lift [a manual lift (lift)] into her wheelchair during a transfer. Based on observation, interview, and record review, the facility failed to ensure the Invacare lift (lift) sling was inspected prior to use for wear and/or frayed areas as indicated in the facility's policy and procedure to prevent an accident for one of one residents (Resident 1). On May 26, 2013, at 10 a.m., Resident 1 was being transferred from the bed into the wheelchair using a lift. The lift sling broke and Resident 1 dropped into the wheelchair, sustaining a left hip fracture that required seven days of hospitalization. Due to her overall condition, the medical team of consultants agreed that she was not an operative candidate, and recommended she would benefit from hospice care. On June 12, 2013, at 9 a.m., the sling that was used during the incident was provided by the director of nurses (DON) for observation. The tan colored sling was clean. The upper portion of the two straps that held the resident was broken off completely and the bottom portion of the straps were frayed. A photo of the sling was taken on the same date of observation. On June 12, 2013, at 12:30 p.m., Resident 1 was interviewed and stated this was the first time the staff had used this sling on her. She stated the nurses usually use the big blue sling for her but they could not find it that morning. She stated she was strapped in and over the chair when she heard two snaps, and then dropped a few inches into the wheelchair. She said she was scared and in pain.According to the admission record, Resident 1 was originally admitted to the facility on December 19, 2011, and was readmitted on June 4, 2013, with diagnoses that included fractured femoral condyle dislocation (fractured left hip), respiratory insufficiency (inability to breath and get adequate gas exchange), acute renal failure (sudden kidney failure), lymphedema (blockage in the lymph system, system that removes waste from the body), osteoarthritis (degenerative joint disease), and morbid obesity (over weight). The Minimum Data Set (MDS) a standardized assessment and care screening tool, dated March 18, 2013, indicated Resident 1 had good short and long term memory with no impairment in her cognitive skills for daily decision-making, and was able to understand or be understood. The resident was totally dependent on staff requiring two plus persons physical assistance during transfers. The Fall Risk Assessment dated April 22, 2013, indicated Resident 1 was at risk for falls. The Monthly Record of Vital Signs and Weight dated May 10, 2013, indicated Resident 1 weighed 344 pounds.The Multidisciplinary Progress Note dated May 26, 2013 at 10 a.m., indicated Resident 1 requested to be transferred from the bed into the wheelchair. The note indicated the resident was being transferred from the bed using an Invacare lift assisted by four certified nursing assistants (CNAs). While the resident was hanging approximately 2 inches over the wheelchair, the front strap of the Invacare lift sling snapped and the resident dropped into the wheelchair.The Multidisciplinary Progress Record dated May 27, 2013, at 3:30 p.m., indicated Resident 1 complained of severe pain on the left hip rated 8 out of 10 (ten being the worst pain a person could experience) and was medicated with Tylenol 500 milligrams (mg). The note indicated the pain decreased to 4 out of 10, the physician was notified and ordered X-Rays of both hips.The X-Ray results dated May 27, 2013 at 6:07 p.m., indicated Resident 1 sustained a displaced (not aligned) intertrochanteric (space between the greater and lesser trochanters [bony prominences toward the near end of the thighbone]) fracture of the proximal (next to) left femur, and severe degenerative changes of the hips.The physician was notified of the X-ray result dated May 27, 2013, and ordered to transfer Resident 1 to a general acute care hospital (GACH). The resident was transferred to GACH at 8:30 p.m. A review of the GACH Discharge Summary dated June 17, 2013, revealed that the entire medical team of consultants decided that the resident was not an operative candidate due to her health risks involved, which included severe chronic obstructive pulmonary disease (progressive disease that makes it hard to breath), pulmonary hypertension (increased blood pressure in the areteries/veins between the heart and lungs), and severe lymphedema, and recommended she would benefit from hospice care. On June 12, 2013, at 11 a.m., during an interview with CNA 1, she stated she was one of the CNAs helping to transfer Resident 1. She stated during the transfer the sling broke, Resident 1 dropped in a wheelchair 1 1/2 to 2 inches. She further stated Resident 1 has two designated slings that they use just for her, which they checked for the weight capacity and size of the sling before using it.At 11:15 a.m., CNA 2, who was present during the transfer incident, stated the sling, hook and joint were checked prior to using it.At 11:45 a.m., CNA 3 was interviewed. He stated he helped to transfer Resident 1 because she was heavy. He stated the resident needed 2-3 people for transfer to hold the Invacare lift sling over the wheelchair. He stated the sling straps broke, the resident went forward and he had to hold the resident back.During an interview on June 12, 2013, at 4:30 p.m., housekeeping staff 1 stated he was not sure of what the facility policy for mechanical lift slings stated, but when he checks, he checks for the cleanliness and if the sling is broken. He stated he checked the slings two weeks ago and there was no problem with them, but did not write anything down in his log book. He stated he does not know specifically which slings belong to which resident; he just checks all slings that come to the laundry after the slings are washed. He was unable to provide documented evidence that any slings were inspected. The undated facility's Housekeeping policy and procedure (P&P) on Mechanical Lift Slings: disinfection and monitoring indicated mechanical lift slings will be inspected prior to use to identify frayed spots or other evidence of wear: Slings will be replaced as needed if evidence of wear and/or frayed areas were identified. The charge nurse will be notified of any sling wear and/or frays. Prior to lifting a resident with slings, the attachments (hooks of the sling) will be inspected to ensure they are properly attached to ensure safe resident transfers. Mechanical lift slings will be inspected for frayed spots and sent to the laundry weekly for disinfection.On June 12, 2013, at 10 a.m., the DON stated each heavy care resident has his/her own Invacare lift sling and the maintenance staff should be checking to make sure the Invacare lift sling is in proper working order. The DON stated that it is the responsibilities of the CNAs/nurses to check for worn/frayed areas before using the sling.A review of the in-service titled "Proper use of Lift " dated January 10, 2013, included a review of the facility's P&P on Mechanical Lifts/Slings; Monitoring function will be inspected daily by CNA prior to use to verify function of sling - no frayed areas, seat, straps, feet and legs of lift. The in-service sign in sheets indicated three of the CNAs involved during the May 26, 2013, incident attended the in-service.During telephone interviews with the administrator on August 22, 2013, at 11:50 a.m., and September 9, 2013, at 4:10 p.m., she stated the blue color with mesh Invacare lift sling is used for showers, and the tan color Invacare lift sling that the resident used when the incident happened is used for regular transfers. She stated each sling can lift a maximum of 450 to 500 pounds. She was unable to provide the invoice as to when the sling that was used during the incident was purchased; she stated the facility uses different vendors. The administrator was unable to verify the age of the sling and stated she had been working in the facility for more than three years and had not purchased slings. A review of the Invacare Product Catalog for the sling used during the transfer incident revealed the sling had a weight capacity of 500 pounds. Therefore, the facility failed to ensure the Invacare lift sling was inspected prior to use for wear and/or frayed areas as indicated in the facility's policy and procedure to prevent an accident for Resident 1. On May 26, 2013, at 10 a.m., Resident 1 was being transferred from the bed into the wheelchair using a lift. The lift sling broke and Resident 1 dropped into the wheelchair, sustaining a left hip fracture that required seven days of hospitalization. Due to her overall condition, the medical team of consultants agreed that she was not an operative candidate, and recommended she would benefit from hospice care.The above violation presented either imminent danger that serious harm would result, or a substantial probability that serious physical harm would result to Resident 1. |
| 970000043 |
ST. JOHN OF GOD RETIREMENT AND CARE CENTER |
910010242 |
A |
07-Nov-13 |
1Z1T11 |
13369 |
F333 483.25(m)(2) The facility must ensure that residents are free of any significant medication errors. On October 18, 2012, at 11:53 a.m., an unannounced visit was made to investigate a complaint alleging Resident 1 was transferred to a general acute care hospital (GACH), unresponsive with a blood sugar of 14 milligrams (mg)/deciliter (dl) (a normal blood sugar range is from 70-100 mg/dl).Based on interview and record review, the facility?s nursing staff failed to ensure Resident 1 was not administered Glipizide (an oral medication prescribed for the treatment of diabetes [a chronic disease in which high levels of glucose (sugar) builds up in the bloodstream]) without a physician?s order and when there was no diagnosis of diabetes mellitus.As a result, Resident 1 had a change in condition, becoming hypoglycemic (low blood sugar), hypothermic (low body temperature), hypoxic (lack of oxygen reaching the body tissues), and was very slow to respond and lethargic (physical slowness and mental dullness), requiring five days of hospitalization, including the Intensive Care Unit. On October 9, 2012, at 9:50 a.m., during a telephone interview, the complainant stated she was called by the facility early one morning and told Resident 1 was cold and clammy and they were transferring her to a GACH. The complainant stated she met the resident at the ambulance and found her non-responsive. The GACH found the resident?s blood sugar level was 19 mg/dl. She stated they gave the resident something that increased her blood sugar, but it kept going down. The GACH conducted a test to determine if the resident had received insulin (medication used to treat diabetes by lowering the level of glucose) or another diabetic medication, which came back positive for Glipizide. The complainant stated Resident 1 was not and had never been diabetic and should not have received any type of diabetic medication. Resident 1?s Admission Records indicated a 99 year-old female admitted to the facility on December 9, 2010, with diagnoses including congestive heart failure (CHF [inability of the heart to pump enough blood to meet the needs of the body]), coronary artery disease (CAD [a buildup of plaque in the heart?s arteries]), depression, morbid obesity, hypertension, gastritis (inflammation of the lining of the stomach), pulmonary embolism (a blood clot in the lung), a history of a stroke, and arrhythmia (an irregular/abnormal heartbeat or heart rhythm).The June 15, 2012, Minimum Data Set, an assessment and care screening tool, indicated Resident 1 had no long or short term memory problems, and required 1 person physical assistance with all her care needs, except eating, where she required set up assistance only.The Recapitulated (recapped) Physician?s Orders, dated August 2012, indicated Resident 1was prescribed the following medications:Carafate for gastritis two times daily before mealsPantoprazole for gastritis once daily Docusate as a stool softener two times daily Cozaar for hypertension once daily Furosemide for CHF once daily in the morning Plavax to prevent a stroke once daily Norvasc for hypertension once daily Albuterol Sulfate combined with Ipratropium Bromide every four hours as needed for shortness of breath (SOB) and congestion. There was no physician?s order for Glipizide. The Facility Nursing Progress Notes, dated August 30, 2012, at 2:50 a.m., indicated Resident 1 was noted with shortness of breath, was verbally unresponsive and restless with cold clammy skin. Her oxygen saturation (a measure of how much oxygen the blood is carrying) was 88 percent (%) (reference range 95%). Oxygen (O2) was administered to the resident via a non-rebreather mask (an O2 mask with a reservoir bag attached that does not allow for rebreathing of exhaled air) at 2 liters per minute (lpm). Documented vital signs indicated blood pressure at 144/59 (reference range systolic [peak pressure in the arteries (top number)]100 to 140, diastolic [when the heart is resting (bottom number)] 60 to 90), pulse 62 beats per minute (bpm) (reference range 60 to 100 bpm), respiration 20 breaths per minute (reference range 12 to 20), and temperature 98.1 degrees Fahrenheit [F] (reference range 98.6 F). The O2 administration was increased to 8 lpm.The Ambulance Patient Care Report, dated August 30, 2012, indicated the resident was found not awake or alert, opened her eyes to painful stimuli, and her pupils were dilated. The resident was placed on 15 lpm of O2 with a non-rebreather mask. The GACH Emergency Room Report dated August 30, 2012, at 4:35 a.m., by the emergency room physician, indicated Resident 1?s temperature was 94.8 F, which was hypothermic (low body temperature), pulse 56 bpm, and O2 saturation was 87% on room air, which was hypoxic (lack of oxygen reaching the body tissue). The report indicated the resident was very slow to respond and lethargic (physical slowness and mental dullness). Laboratory results indicated her blood glucose level was 19 mg/dl. The emergency room physician documentation indicated it was suspected there may have been some mix-up with the resident?s medication at the nursing home because the resident was not a diabetic, the resident was not on any medication that would drop her blood sugar, she was not septic, and she did not have insulinoma (a tumor in the pancreas that produces too much insulin). A Consultation report dated August 31, 2012, by the endocrinologist (a physician that diagnoses and treats diseases that affect your glands) indicated on the previous day, August 30, 2012, Resident 1was unconscious with a blood glucose level of 19 mg/dl. The resident was given a rescue dose of D50 (dextrose [sugar] 50%, used to increase blood sugar level in diabetic residents whose sugar level drops). The resident continued to be hypoglycemic (an unusually low level of sugar in the blood) in the emergency room and was started on dextrose 10% at 60 milliliters (ml) per hour. The consultation report indicated despite being on dextrose, the resident?s blood glucose kept on dropping. Dextrose 10% was increased from 60 ml to 120 ml per hour but despite this fact, the resident?s blood glucose kept on dropping. The resident was transferred to the Intensive Care Unit (ICU) for very close monitoring of her blood glucose level every hour. Continued documentation indicated the endocrinologist suspected ingestion of a long-acting sulfonylurea (a class of anti-diabetic drugs used in the management of diabetes mellitus type 2), which might have been administered by mistake at the skilled nursing facility. The endocrinologist indicated a blood test would be conducted to screen for oral hypoglycemic agents.Laboratory test results, dated August 31, 2012, indicated Resident 1?s blood was positive for the presence of Glipizide.On October 18, 2012, at 11:53 a.m., during an interview, the director of nursing (DON) stated there was one other resident (Resident 2) who was two doors away from Resident 1?s room, who was prescribed Glipizide. She stated there was one medication cart and one medication nurse used for that section where both Resident 1 and Resident 2 resided. On October 18, 2012, at 1:30 p.m., an observation of the facility?s 3rd floor, where Resident 1 and Resident 2 resided, revealed their rooms were across and slightly at an angle from each other, approximately two doors away.A review of Resident 2?s Admission Records indicated a 75 year-old male, admitted to the facility on September 3, 2011, with a diagnosis of diabetes mellitus. The Physician?s Orders, dated September 3, 2011, indicated he was prescribed to receive Glipizide 10 mg, twice a day, for diabetes. A review of the Medication Record dated August 2012 indicated Resident 2 received Glipizide 10 mg, twice a day at 9 a.m. and 5 p.m., daily. On October 18, 2012, at 1:24 p.m., during an interview, Resident 1 stated she went to the hospital because someone at the facility gave her the wrong pill. She stated she did not remember what happened but was told by the doctor that she was given the wrong medication. She stated whatever the nurse gave her it almost killed her. On December 27, 2012, at 10:30 a.m., during a telephone interview, the licensed vocational nurse (LVN 1) stated medication errors do occur but to the best of his recollection he did not give the wrong medication to Resident 1. On September 11, 2013, at 1 p.m., during an interview, LVN 1 stated he worked the 7 a.m. to 3 p.m. shift on August 29, 2012, and did not remember anything odd regarding Resident 1?s behavior.On September 11, 2013, at 10:04 p.m., during an interview, a certified nursing assistant (CNA 2) stated on August 29, 2012, on the 3 p.m. to 11 p.m. shift, she observed Resident 1 in bed and she was very sleepy. CNA 2 stated she reported to LVN 3 that Resident 1 looked sick and she couldn?t talk very well; she was sweating and wouldn?t open her eyes completely. CNA 2 stated Resident 1 was normally up in her wheelchair, talking and happy. She stated the resident normally had a good appetite (ate everything) but that night she was in bed early and only ate about 25% of her food. She stated she had to change the resident?s diaper and clean her up 2 to 3 times, ?a lot of poop? and the resident complained that she was sick. On September 11, 2013, at 11:26 a.m., during a telephone interview, LVN 3 stated on August 29, 2012, at approximately 3 p.m., CNA 2 reported to her that Resident 1 was feeling sleepy and was sweaty. LVN 3 stated she went to the resident?s room and observed her in bed. She stated the resident told her she felt sleepy and she observed the resident was sweating a lot. Later that evening LVN 3 noticed the resident had not eaten much of her dinner and the resident stated she was tired and just wanted to sleep. LVN 3 stated both Resident 1 and Resident 2 were very alert. She stated she checks all medications before she administers them and was sure she did not give the wrong medication to Resident 1.On December 27, 2012, during a telephone interview, LVN 2 stated on August 30, 2012, at approximately 3 a.m., CNA 1 reported to him that Resident 1 was making funny noises. He went to the resident?s room and observed the resident to be confused and sweating. He stated she was trying to speak but it was garbled and did not make sense. He reported to RN 1 that the resident was not behaving normally. He stated he did not receive a report from anyone on the previous shift regarding a change of condition or concern for Resident 1.On December 27, 2012, during a telephone interview, registered nurse 1 (RN 1), who was the RN supervisor, stated on August 30, 2012, the licensed vocational nurse (LVN 2) reported to her that Resident 1 was not behaving like she usually did. RN 1 stated she went to the resident?s room and observed her to be restless (moving her arms and legs around). RN 1 stated she asked the resident ?how are you?? but the resident just looked at her and continued to move around a lot. RN 1 stated the resident was really sweating with cold clammy skin. She then called the physician and an order was given to transfer the resident to a GACH. On September 11, 2013, at 3:53 p.m., during a telephone interview with the GACH endocrinologist it was stated Glipizide, an antidiabetic medication, was found in Resident 1?s blood, and was the reason her blood sugar kept dropping and would not stabilize. He stated the resident left the facility where she had been residing with symptoms of hypoglycemia and that was how she presented in the GACH?s emergency department.Once the medication was eliminated from the resident?s system she returned to her normal baseline. He stated the critical drop in her blood sugar could have caused her to go into a coma and could have led to her death; he did not know if there would be any long term effects. On September 16, 2013, at 9:55 a.m., during a telephone interview, Resident 1?s attending physician indicated Glipizide is a common medication given to diabetic residents, but Resident 1 was not diabetic and had not been prescribed Glipizide. He stated Glipizide is a long acting diabetic medication, which explains why the resident?s blood sugar would not stabilize. When asked what he thought happened and how the medication got in the resident?s system, he stated he did not suspect it was given to her intentionally to cause her harm, but apparently a wrong medication was given to her at the skilled nursing facility. He stated it was highly unlikely the medication error occurred at the hospital because Glipizide was not an emergency room medication, and if a patient had a high blood sugar, insulin would be given. There was no order for Glipizide and the resident presented to the emergency department with symptoms of hypoglycemia.Therefore the facility?s nursing staff failed to ensure Resident 1 was not administered Glipizide without a physician?s order and when there was no diagnosis of diabetes mellitus. As a result, Resident 1 had a change in condition, becoming hypoglycemic, hypothermic, hypoxic, was very slow to respond and lethargic, requiring five days of hospitalization, including the Intensive Care Unit. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would and did result to Resident 1. |
| 910000330 |
SHARON CARE CENTER |
910011246 |
A |
05-Feb-15 |
P9JD11 |
8868 |
Title 22 ? 72523 Policy 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 a complaint, dated January 24, 2013. According to the complaint, a patient (Patient A) upon admission to the general acute care hospital (GACH) from the skilled nursing facility (SNF) was neglected. The complaint alleged the SNF did not properly care for the patient?s abnormal wound which resulted in an unnecessary admission to the hospital and required an emergency surgical repair of the wound.Based on record review and interview, the facility failed to: Have policies and procedures in place to indicate how to apply, care for, monitor and discontinue a wound vacuum (VAC/vacuum assisted closure) a machine to enhance wound healing. This failure resulted in a sponge being left in Patient A?s abdominal wound, after the VAC was discontinued, on January 15, 2013. The patient was sent to the GACH on January 18, 2013, for a possible infected ileostomy that was located several inches from the abdominal wound. While in the ER, the patient had altered mental status (obtunded) and low blood pressure at 53/32 (120/80 normal reference range), and required mechanical ventilation (by a ventilator). The GACH?s physicians found the patient?s ileostomy and abdominal wound to be infected, which required Patient A to be admitted to the intensive care unit (ICU) and undergoing an emergency exploratory surgery. During surgery, the surgeons discovered a VAC sponge embedded in the patient?s abdominal wound. On February 19, 2013, an unannounced complaint investigation was initiated. On November 19, 2014, at approximately 10 a.m., the complaint investigation follow-up was conducted. During an interview, the director of nursing (DON) and administrator were asked to produce a copy of the facility?s policy on applying, caring for, monitoring and discontinuing a VAC from a patient?s wound. Both, the DON and administrator, stated the facility did not have policies or procedures for the use of a wound VAC. They stated the facility uses the guidelines/directions from the VAC manufacture instead.A review of Patient A?s face sheet indicated the patient was a 41 year-old female who was re-admitted to the facility on January 8, 2013 with diagnoses that included end stage renal failure (ESRD/the kidneys are no longer able to work at a level needed for day-to-day life), hypertension (high blood pressure), ileostomy (a surgical operation in which a piece of the ileum is diverted to an artificial opening in the abdominal wall), history of hemorrhagic CVA (cardio vascular accident and stroke) and depression. A review of Patient A?s medical record indicated on January 8, 2013, the patient was re-admitted from the GACH to the skilled nursing facility (SNF) secondary to a partial bowel resection. According to an untitled form, dated January 9, 2013, signed by a license vocational nurse (LVN), the patient was admitted to the SNF with an open wound to the left abdomen area, measuring 16 by 9 by 3.2 centimeters (cm) in size. A review of the patient?s admission physician?s orders, dated January 8, 2013, indicated to apply a wound VAC to the left abdominal wound, change left abdominal wound VAC every Tuesday, Thursday, and Saturday, and PRN (when necessary) if soiled or dislodged, cleanse with normal saline, pat dry, fit black foam to wound, secure with clean dressing, connect to wound VAC for 14 day until January 23, 2013. The wound VAC was to be set at 125 millimeters of mercury (mmhg) negative pressures (suction pressure) and to change wound VAC canister every Tuesday, Thursday, Saturday and PRN (whenever necessary) if full for 14 days until January 23, 2013. A review of the treatment record, dated for the month of January 2013, indicated the patient had wound VAC sponge changes done on January 9, twice on the 10th, 12, and 14, 2013. On January 15, 2013, the physician ordered to discontinue the wound VAC. According to the wound care records for January 2013, after the wound VAC was discontinued, the physician ordered to clean the wound and apply a dressing. A review of the licensed nursing note, dated January 19, 2013, and timed at 1:12 a.m., (indicating a late entry for January 18, 2013, 3 to 11 p.m. shift) indicated the patient pulled out the ileostomy and refused to have her wound dressing changed. According to the note, the same day, at 8 p.m., the patient was transferred to the GACH. On December 1, 2014, a review of the GACH?s emergency room summary, dated January 18, 2013, indicated Patient A?s diagnoses included sepsis (severe infection that spreads via the bloodstream), hypotension (low blood pressure), abdominal wall cellulitis (serious acute bacterial infection of skin and subcutaneous tissue), with severe inflammation and history of end stage renal disease. While in the emergency room, the patient received a central line (intravenous line inserted into a large vein, typically in the neck or near the heart for therapeutic or diagnostic purposes), and antibiotics, then the patient was admitted to the ICU. The record indicated upon discharge from the emergency room the patient was ?critical? (A disease or state in which death is possible or imminent). According to the GACH?s medical records, the patient was taken to surgery on January 19, 2013. The pre-operation diagnosis was ?Retained VAC sponge within the wound, as well as a complex abdominal wall break down.? The operative findings of the report indicated an entire sponge was removed with some difficulty. The patient was sent back to the ICU. A review of the GACH?s discharge summary, dated April 11, 2013, indicated the patient was very weak and was sent to another skilled nursing facility (SNF) for follow-up care.On December 11, 2014, at 10:45 a.m., the DON was asked if the facility was aware the GACH had found a VAC sponge in Patient A?s left abdominal wound. The DON stated she could not answer any questions regarding the incident involving Patient A because she was not the DON at that time. The DON was asked how she currently ensures the treatment nurses are providing the proper care for the facility?s VAC treatments since the facility did not have a policy on how the treatments should be done. The DON stated, ?The wound care nurses are trained by the VAC manufacturer and are given in-services.?On December 11, 2014, at 11:30 a.m., an interview was conducted with the wound care nurse (LVN 1) who discontinued the VAC from Patient A. When asked how did she removed Patient A?s VAC set-up, she stated she removed the set-up, wound dressing, the sponge she saw, and implemented the new physician?s order. When asked if she was sure she removed all of the sponges from the wound, LVN1 stated the wound was deep and partially closed so she just removed what she saw. When questioned about the sponge changes during the wound care prior to the discontinuance of the wound VAC, she stated the nurse who did the sponge changes no longer worked at the facility. LVN 1 was asked about charting after removing the wound VAC. According to LVN 1, she documented on the January 2013?s wound care sheet and charted in the computer. When asked if she charted the number of sponges removed and the description of the patient?s wound she stated, ?Not really.?A review of the nurse?s note, dated January 15, 2013, indicated the nurse called the physician because the wound was leaking, so the physician gave an order to discontinue the VAC and gave new wound care orders. There was no documentation indicating the number of sponges applied and removed as indicated by the VAC?s manufactures guidelines and there was no verification there was complete removal of the sponges.A review of the VAC?s manufacture guidelines titled, ?KCI VAC Therapy Points to Remember When Using VAC Therapy,? Pages 6 and 12, indicated, when the dressing is removed, count the number of foam pieces applied and removed, correlate the count with the number of pieces previously placed in the wound and verify the complete removal of all VAC foam dressing pieces. The guideline booklet also indicated, in addition to counting the sponge pieces, the nurse should document the foam quantity in the patient?s chart. There was no documented evidence the facility was following the manufactures guidelines as they indicated. The facility failed: To have policies and procedures in place to indicate how to apply, care for, monitor and discontinue a wound VAC from a wound. The above violations jointly, separately or in any combination presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 910000330 |
SHARON CARE CENTER |
910011274 |
B |
18-Feb-15 |
TPDP11 |
4793 |
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. On October 28, 2011 at 1 p.m., an unannounced complaint investigation was initiated regarding Patient 5 who left the facility through the back door without the staff?s knowledge. While out of the facility, Patient 5 fell and was taken to the general acute care hospital (GACH), emergency room by the paramedics for treatment of her injuries. Based on observation, interview and record review, the facility failed to implement the facility?s elopement policy and procedure by not testing the door alarm and documenting the tests result daily. As a result, the staff did not know Patient 5 had left the facility. Patient 5 fell while out of the facility and sustained a fractured nose, and facial lacerations (deep cut).A review of the medical record indicated Patient 5 was admitted to the facility on September 24, 2011, with diagnoses including Alzheimer?s disease (progressive loss of brain function), and dementia (loss of brain function). A review of the Minimum Data Set (MDS) assessment, dated September 30, 2011, indicated Patient 5 was able to make herself understood and had independent cognitive skills for daily decision-making. The MDS indicated Patient 5 had unsteady balance during transfers and while walking. Patient 5 required extensive assistance from staff while walking in her room, in the corridor and on the unit.The Licensed Nurse Daily and Every Shift Charting, dated October 9, 2011 at 11 p.m., indicated the charge nurse received a phone call from Patient 5?s family member. The documentation indicated Patient 5 had been found outside of the facility, on the street by a stranger, had sustained a fall and was bloody. Patient 5 was picked up by the paramedics and taken to the general acute care hospital (GACH). A review of the Interdisciplinary Team (IDT) notes, dated October 10, 2011, indicated the charge nurse stated Patient 5 was last seen the night of the incident (10/9/11) around 10 p.m. lying in bed watching television. The IDT notes indicated a certified nursing assistant (CNA) last saw Patient 5 in her room around 9 - 9:30 p.m. The IDT notes dated October 10, 2011, indicated the viewing of a security video showed Patient 5 leaving the facility through the back door at 11:02 p.m.The IDT notes dated October 11, 2011, indicated the maintenance staff set the alarm for the back door. It was indicated the alarm would be set for 7 p.m. so the staff could monitor if anyone was trying to get in or out of the building. However, there was no system in place (maintenance log or visual check) to confirm if the alarm had actually been set the evening of Patient 5?s elopement. A facility policy and procedure on Elopement, dated May 9, 2008, indicated the purpose of the policy included minimizing the episodes of elopement. The policy defined elopement as a patient with impaired cognitive making abilities leaving the facility without the staff?s knowledge. The policy indicated door alarms, if applicable, would be tested daily and the results recorded on a designated log. There was no indication the staff conducted daily testing of the door alarms. On October 28, 2011 at 2:25 p.m., CNA 1 stated she worked with Patient 5 the evening of the incident. CNA 1 stated she last saw the patient around 9 ? 9:30 p.m. that evening. CNA 1 stated the patient was alert but she was not sure if the patient was oriented. CNA 1 denied hearing any type of alarm that evening related to the back door. On October 28, 2011 at 3:10 p.m., the licensed vocational nurse (LVN 2) stated Patient 5 ambulates slowly with a cane and had slight hand tremors. LVN 2 was not aware of the back door being alarmed. On October 28, 2011 at 3:40 p.m., the director of nursing (DON) stated Patient 5 was alert and oriented and often spoke about her son and going back to her previous residence. However, the DON did not consider Patient 5 an elopement risk. The DON stated they are not a locked facility and the back door was not locked at the time of the incident. The DON stated the back door does lead to the alley and it had an alarm but the alarm was not set the evening Patient 5 left the facility.The facility failed to implement the facility?s elopement policy and procedure by not testing the door alarm and documenting the test results daily. As a result, the staff did not know Patient 5 had left the facility. Patient 5 fell while out of the facility and sustained a fractured nose, and facial lacerations. The above violation had a direct relationship to the health and safety or security of patients. |
| 910000076 |
SANTA MONICA CONVALESCENT CENTER II |
910011439 |
B |
26-May-15 |
I8Y411 |
4903 |
F226 CFR 483.13(c)(2), 483.13(c)(4) Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation.483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). 483.13(c)(4) The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On January 30, 2014 at 2:35 p.m., an unannounced visit was made to the facility to investigate a complaint alleging a resident had been struck in her face by a nurse. Based on interview and record review, the facility?s staff failed to follow their abuse policy by failing to: Report allegations of abuse to the department of public health (DPH), made by the resident?s responsible party, after bruises were found on the resident?s right chin and right arm. On January 30, 2014 at 2:50 p.m., during an interview, the Director of Nursing (DON) stated Resident 1?s responsible party reported someone hit the resident on her chin. She stated a nickel sized discoloration was found on the resident?s chin and she did not see any other bruising. The DON reported the resident stated she did not know how it happened and that some nurses are nice and some are not. The resident is often confused and has a history of hallucinations. On January 30, 2014 at 3:48 p.m., during an interview, the Administrator stated on Sunday, January 5, 2014, the day after the incident occurred, the director of staff development (DSD) called him at home to report the police were at the facility investigating an allegation of abuse made by Resident 1?s responsible party. The administrator stated he did not report the incident to the DPH immediately because he was sick and the investigation had not been done yet. He stated, what was he going to report to the DPH without an investigation? A transmittal letter from, the facility?s administrator, regarding an unknown injury investigation report indicated the letter was dated, January 14, 2014, (9 days after the administrator was made aware of the allegation of abuse). On January 30, 2015 at 5:20 p.m., Resident 1 was observed sitting in the dining room. She was alert and oriented as evidenced by her talking, however, when asked about the abuse allegation she would not comment. There were no noticeable bruises on her extremities or face. A review of Resident 1?s Admission Records indicated an 89 year-old female was admitted to the facility on October 24, 2011, with diagnoses that included dementia (a progressive loss of mental ability), cognitive deficits due to cerebrovascular disease (any disorder that affects the blood vessels that provide oxygen rich blood to a person?s brain) and blindness. Licensed Nurses Progress Notes, dated January 5, 2014 at 10:25 a.m., indicated Resident 1?s responsible party reported the resident told him she was punched the day before (January 4, 2014) by a nurse. Continued documentation indicated that at approximately 11 a.m., two policemen arrived at the facility to investigate the allegation of abuse. On January 5, 2015 at 6:08 p.m., during a telephone interview, Resident 1?s responsible party stated he visited the resident on Friday (not sure of the date) and there were no bruises on her body. He returned to the facility the next evening (Saturday) and noticed a bruise on the resident?s right chin and right wrist. The resident told him a nurse grabbed her arm and struck her in the face. He returned to the facility the next morning and after receiving no satisfactory explanation called the police.A facility policy on Abuse, dated May 1997, indicated residents of the long-term facility are protected from any physical and mental mistreatment. For employee to resident abuse the police, ombudsman at the department of aging, and the department of public health are notified as required by law. Based on interview and record review, the facility?s staff failed to follow their abuse policy by failing to: Report allegations of abuse to the department of public health (DPH), made by the resident?s responsible party, after bruises were found on the resident?s right chin and right arm. This violation had a direct relationship to the health, safety or security of residents. |
| 910000330 |
SHARON CARE CENTER |
910011600 |
B |
07-Jul-15 |
PNDP11 |
6820 |
483.13(b) Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Based on interview and record review, the facility failed to ensure Resident 1 was treated as an individual with dignity and respect and was not subjected to verbal abuse of any kind.When Resident 1 lost control of her bladder and urinated on the floor, certified nursing assistant, (C. N.A.) 6 called Resident 1 a ?vieja cocina,? which translated means ?dirty old lady.?As a result, Resident 1 felt embarrassed, cried and felt bad about herself. On September 17, 2014 at 7 a.m., an investigation was conducted to investigate an entity reported allegation of verbal abuse. According to Resident 1's, Admission Face Sheet, the resident was admitted to the facility on August 20, 2014, with cerebral artery occlusion (stroke) and major depression. The resident's primary language was Spanish.A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated August 27, 2014, indicated the resident was cognitively intact, had clear speech and was understandable. The MDS indicated the resident had no behavioral problems, required extensive physical assistance from one staff person with her activities of daily living and was incontinent of bowel and bladder. The resident was unsteady when standing and required staff assistance for stabilization when standing. During an interview with Resident 1, through a Spanish interpreter, on September 17, 2014 at 8:05 a.m., Resident 1 was asked if there had been any problems with the nursing staff members. Resident 1 replied "Yes." Resident 1 was asked to explain the problem. Resident 1 said on September 1, 2014 at 11 a.m., she was sitting in her wheelchair in her room. Resident 1 stated that she requested assistance to use the restroom and then to be placed in bed. Resident 1 also said that CNA 6 came to the resident's room and told her that she was finishing up in a neighboring room and that she will be back when she finished. When CNA 6 left the room, Resident 1 attempted to transfer herself to the restroom and in the process lost control of her bladder and urinated on the floor. Resident 1 then said that when CNA 6 returned to her room to assist the resident to the restroom CNA 6 was very upset to see urine on the floor. She raised her voice and said, "Why did you do that? I told you not to do that and now look what you did." Resident 1 stated that CNA 6 verbalized that now she has to use her lunch time to clean the urine off the floor and that point CNA 6 called the resident a "vieja cocina" which translates in English to "dirty old lady." Resident 1 stated she was embarrassed and felt bad about herself. A review of Resident 1's documented interview with administrator, dated September 2, 2014, confirmed that Resident 1 conveyed the same story to the administrator. Resident 1 reported to the administrator that CNA 6 spoke aggressively toward her, used a loud tone and called her a "vieja cocina."According to the documented interview Resident 1 stated when CNA 6 returned to the resident's room CNA 6 began to get upset with Resident 1 as she was cleaning the resident and was not being nice. Resident 1 stated CNA 6 called her a "vieja cocina" which translated to dirty old lady. Resident 1 was offended by this remark. At the conclusion of a documented interview with the administrator, Resident 1 was asked if there was anyone present that could have heard what occurred. Resident 1 stated Housekeeper 9 was present. During an interview with Housekeeper 9, on September 17, 2014 at 7:50 a.m., Housekeeper 9 was asked what she observed or heard the day of the incident. Housekeeper 9 said she did not observe anything, however she overheard CNA 6 speaking loudly in Resident 1's room. The facility's investigative report, dated September 2, 2014, included a documented interview with Housekeeper 9 conducted by the facility's administrator. According to this interview the administrator asked Housekeeper 9 if on the morning of September 1, 2014, she heard anything occur in Resident 1's room. Housekeeper 9 stated that she heard a dispute between Resident 1 and CNA 6. Housekeeper 9 stated she heard CNA 6 telling Resident 1, "Why would you do that, now I have to clean up! Now instead of eating lunch, I need to take care of this." Housekeeper 9 stated CNA 6 was reprimanding Resident 1. The administrator asked Housekeeper 9 if she heard CNA 6 saying words 'vieja cocina" to which Housekeeper 9 said no. Housekeeper 9 stated while she was cleaning, CNA 6 came out of Resident 1's room and said "Did you see what that vieja cocina did to me?" Housekeeper 9 said she went to Resident 1's room afterwards and spoke to the resident about the incident. Housekeeper 9 stated Resident 1 was very upset.During an interview on September 17, 2014 at 9:45 a.m., the administrator stated CNA 7 found Resident 1 crying in her room on September 1, 2014, and because CNA 7 did not speak Spanish she informed the Activity Assistant about her observation. The administrator stated CNA 6 was immediately suspended pending the completion of the investigation. The facility's investigative report dated September 2, 14, also included documentation of an interview with the Activity Assistant. According to the documented interview, Resident 1 told the Activity Assistant that CNA 6 called her nasty. The CNA Report of Misconduct form, dated September 2, 2014, indicated CNA 6 was suspended on September 1, 2014, and then terminated on September 9, 2104. A review of the facility's FINAL REPORT on Allegation of Abuse, dated September 2, 2014, indicated the facility was able to substantiate CNA 6's inappropriate tone and behavior toward Resident 1. According to the report the facility investigation did not confirm if CNA 6 called Resident 1 "vieja cocina" directly, but the facility was able to confirm through an employee that CNA 6 stated Resident 1 was a, "vieja cocina." During a telephone interview with CNA 6 on September 17, 2014 at 2:40 p.m., she denied calling Resident 1 nasty and she did not discuss the incident about the resident urinating on the floor with anyone in the facility.The facility's policy and procedure titled, "Abuse Prevention" dated July 1, 2005, indicated each resident has the right to be free from verbal, sexual, physical, and mental abuse. The facility failure to ensure Resident 1 was treated as an individual with dignity and respect and not subjected to verbal abuse of any kind resulted in Resident 1 feeling embarrassed, crying and feeling bad about herself. The above violation has a direct relationship to the health safety or security of patients. |
| 910000077 |
SEACREST CONVALESCENT HOSPITAL |
910011687 |
B |
16-Oct-15 |
NWZY11 |
6145 |
F 225 Criminal Screening, Investigation and Reporting 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). F 226 Staff Treatment of Residents 42 CFR 483.13(c)(4) The results of all investigation must be reported to the administrator or his designated representative and to other officials in accordance with state law (including to the state survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On July 21, 2015, during the initial tour of a recertification survey, the Director of Staff Development (DSD), stated Resident 7 sustained a fracture to his left leg. She stated the resident had no reported falls or other trauma and the fracture was thought to be pathological (occurs when a bone breaks in an area that is weakened by another disease process, i.e., tumors, infection, and certain inherited bone disorders). The DSD was not sure if the facility had reported the injury of unknown origin to the Department of Public Health (DPH). Further investigation indicated the injury of unknown origin had not been reported to the DPH. Based on interview and record review, the facility?s nursing staff failed to: Ensure an injury of unknown origin was reported to the DPH. A review of Resident 7's Admission Records indicated he was readmitted to the facility on April 23, 2013, with diagnoses including dementia (progressive loss of mental ability), osteoporosis (brittle bones) and epilepsy (a brain disorder in which a person has repeated seizures).A review of Minimum Data Set (MDS) assessment, dated April 5, 2015, indicated Resident 7 was totally dependent on the nursing staff and required two staff to provide physical assistance to move in the bed and to transfer in and out of the bed. The resident?s balance during surface to surface transfer was not steady and he was only able to stabilize with assistance from staff. Resident 7 had a functional limitation in range of motion [(ROM), the distance and direction a joint can move to its full potential] to both of his lower extremities and was incontinent (involuntary voiding of urine and stool) of both bowel and bladder function.A review of Situation Background Assessment Recommendation (SBAR), dated May 13, 2015, indicated a certified nursing assistant (CNA) on May 13, 2015, at 7 a.m., turned Resident 7 to his right side and noted he was in pain as evidenced by facial grimacing, yelling/moaning and swinging his hand.According to the licensed nurse?s assessment, documented on SBAR, Resident 7 had mild swelling from his left hip to his left foot with more swelling at his left knee, which was painful and warm when touched. There was no bruising or discoloration noted. On July 23, 2015 at 7:15 a.m., during an interview, the licensed vocational nurse 1 (LVN 1) stated on May 13, 2015, in the morning, he received a report from a licensed nurse of 11 p.m. to 7 a.m., shift, who told him Resident 7 had pain and swelling to his left leg.LVN 1 stated he thought it might have been related to Resident 7?s history of deep vein thrombosis [(DVT), a blood clot in a deep vein, usually in the legs] and was going to monitor him. LVN 1 stated that on May 13, 2015, at approximately 7 a.m., a restorative nursing assistant (RNA) reported to him that she attempted to weigh the resident but could not because the resident was in a lot of pain. An x-ray was ordered, which came back negative for a fracture. LVN 1 stated the medical director came to the facility to evaluate Resident 7 for something else; they reported to the medical director the resident?s condition (leg pain), an examination was done and the medical director ordered the resident to be transferred to a general acute care hospital (GACH) for another x-ray, which came back positive for a fracture. A review of x-ray report, dated May 13, 2015, indicated Resident 7 had no fracture, dislocation or other abnormalities of his left hip. No fracture, dislocation or degenerative changes to his left knee. No fracture, bony destructive lesions or other abnormalities to his left tibia/fibula. No fracture, dislocation or other abnormalities to his left foot. A review of the x-ray report from GACH, dated May 14, 2015, indicated Resident 7 had an acute non-displaced fracture involving the inferior aspects of the lateral tibia plateaus (shinbone) and moderate osteopenia (bone loss that is not as severe as in osteoporosis). According to the Progress Note dated May 14, 2015 at 10:11 p.m., Resident 7?s physician was in the facility with report of x-ray results; acute fracture of interior aspects of lateral and tibial plateaus. On July 24, 2015, at 5:15 p.m., during an interview, the administrator stated Resident 7?s fracture of unknown origin was not reported to the DPH because the resident had osteoporosis and it was concluded the fracture was pathological and no abuse had occurred.According to the facility?s policy on Investigating Unexplained Injuries, not dated, there was no documented evidence to indicate the reporting of unexplained/unknown injury to the DPH was included in the policy. On July 21, 2015, during the initial tour of a recertification survey, the Director of Staff Development (DSD), stated Resident 7 had sustained a fracture to his leg. She stated the resident had no reported falls or other trauma and the fracture was thought to be pathological. Further investigation indicated the injury of unknown origin had not been reported to the DPH. Therefore the facility?s nursing staff failed to: Ensure an injury of unknown origin was reported to the DPH. This violation presented a direct or immediate relationship to the health, safety, security, or welfare of the resident. |
| 910000077 |
SEACREST CONVALESCENT HOSPITAL |
910011802 |
B |
29-Oct-15 |
NWZY11 |
5699 |
F225 Criminal Screening, Investigation and Reporting42 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). 42 CFR 483.13(c)(4) The results of all investigation must be reported to the administrator or his designated representative and to other officials in accordance with state law (including to the state survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. On July 21, 2015, during the initial tour of a recertification survey, the Director of Staff Development (DSD), stated Resident 7 sustained a fracture to his left leg. She stated the resident had no reported falls or other trauma and the fracture was thought to be pathological (occurs when a bone breaks in an area that is weakened by another disease process, i.e., tumors, infection, and certain inherited bone disorders). The DSD was not sure if the facility had reported the injury of unknown origin to the Department of Public Health (DPH). Further investigation indicated the injury of unknown origin had not been reported to the DPH. Based on interview and record review, the facility?s nursing staff failed to: Ensure an injury of unknown origin was reported to the DPH. A review of Resident 7's Admission Records indicated he was readmitted to the facility on April 23, 2013, with diagnoses including dementia (progressive loss of mental ability), osteoporosis (brittle bones) and epilepsy (a brain disorder in which a person has repeated seizures).A review of Minimum Data Set (MDS) assessment, dated April 5, 2015, indicated Resident 7 was totally dependent on the nursing staff and required a two person physical assist for bed mobility and to transfer. The resident?s balance during surface to surface transfer was not steady and he was only able to stabilize with staff assistance. Resident 7 had a functional limitation in range of motion [(ROM), the distance and direction a joint can move to its full potential] to both of his lower extremities and was incontinent (involuntary voiding of urine and stool) of both bowel and bladder function.A review of Situation Background Assessment Recommendation (SBAR), dated May 13, 2015, indicated a certified nursing assistant (CNA) on May 13, 2015, at 7 a.m., turned Resident 7 to his right side and noted he was in pain as evidenced by facial grimacing, yelling/moaning and swinging his hand. According to the licensed nurses assessment, documented on SBAR, Resident 7 had mild swelling from his left hip to his left foot with more swelling at his left knee, which was painful and warm when touched. There was no bruising or discoloration noted. On July 23, 2015, at 7:15 a.m., during an interview, licensed vocational nurse 1 (LVN 1) stated on May 13, 2015, in the morning, he received a report from a licensed nurse on the 11 p.m. to 7 a.m., shift, who told him Resident 7 had pain and swelling to his left leg. LVN 1 stated he thought it might have been related to Resident 7?s history of deep vein thrombosis [(DVT), a blood clot in a deep vein, usually in the legs] and was going to monitor him. LVN 1 stated that on May 13, 2015, at approximately 7 a.m., a restorative nursing assistant (RNA) reported to him that she attempted to weigh the resident but could not because the resident was in a lot of pain. An x-ray was ordered, which came back negative for a fracture. LVN 1 stated the medical director came to the facility to evaluate Resident 7 for something else; they reported to the medical director the resident?s condition (leg pain), an examination was done and the medical director ordered the resident to be transferred to a general acute care hospital (GACH) for another x-ray, which came back positive for a fracture. A review of x-ray report, dated May 13, 2015, indicated Resident 7 had no fracture, dislocation or other abnormalities of his left hip. No fracture, dislocation or degenerative changes to his left knee. No fracture, bony destructive lesions or other abnormalities to his left tibia/fibula. No fracture, dislocation or other abnormalities to his left foot. A review of the x-ray report from GACH, dated May 14, 2015, indicated Resident 7 had an acute non-displaced fracture involving the inferior aspects of the lateral tibia plateaus (shinbone) and moderate osteopenia (bone loss).On July 24, 2015, at 5:15 p.m., during an interview, the administrator confirmed Resident 7?s fracture of unknown origin was not reported to the DPH.According to the facility?s policy on Investigating Unexplained Injuries, not dated, there was no documented evidence to indicate the reporting of unexplained/unknown injury to the DPH was included in the policy. On July 21, 2015, during the initial tour of a recertification survey, the Director of Staff Development (DSD), stated Resident 7 sustained a fracture to his leg. She stated the resident had no reported falls or other trauma and the fracture was thought to be pathological. Further investigation indicated the injury of unknown origin had not been reported to the DPH. Therefore the facility?s nursing staff failed to: Ensure an injury of unknown origin was reported to the DPH. This violation presented a direct or immediate relationship to the health, safety, security, or welfare of the resident. |
| 970000043 |
ST. JOHN OF GOD RETIREMENT AND CARE CENTER |
910012328 |
A |
16-Jun-16 |
J0TU11 |
13217 |
Citation: A 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. 72311 (a) (3) Nursing services (a) Nursing 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 the health professionals involved in the care of the patient. (3) Notifying the attending promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. 72313(a) (2) Nursing services- Administration of Medications and Treatments (a) Medications and treatments must be administered as follows: (2) Medications and treatments must be administered as prescribed On March 22, 2011, at 12 p.m., an unannounced visit was made to the facility to investigate a complaint allegation that Patient 1 was assaulted by his roommate and consequently, sustained a nasal bone fracture (broken nose), a facial orbit fracture (the socket of the skull where the eyes are located) and a lateral right maxillary sinus fracture (below the eyes within the cheek region). Based on interview and record review, the facility failed to ensure Patient 1 was free from physical abuse by failing to: 1. Assess Patient 2 who was pacing from 1 a.m. to 3 a.m., (a total of two hours) in the hallway, and shaking the exit door handle two times, as a sign of anxiety or restlessness and assess the reason why the resident was agitated and intervene. 2. Administer Neurontin (an anti-seizure [anti-convulsant] drug) as ordered by the physician for anxiety or restlessness. 3. Promptly notify the attending physician of Patient 2?s anxiety, agitation and restlessness Consequently, Patient 2 in his state of anxiety and agitation assaulted Patient 1 who sustained multiple injuries. On March 5, 2011, at 3:30 a.m., Patient 2 was found hitting Patient 1?s face with a closed fist. Patient 1 was transferred to a general acute care hospital (GACH) for evaluation and treatment. The Computed Tomography (CT, is an imaging procedure that uses special x-ray equipment to create detailed pictures, or scans, of areas inside the body) showed an acute (new) nondisplaced fracture of the anterior (front), and posterior (back) wall of the right maxillary sinus and an acute fracture of the nasal septum (the dividing wall inside the nose) bone. Patient 1 underwent an exploration and repair of the right orbital blowout fracture (bones surrounding the eye) with alloplastic (synthetic nasal) implant, closed reduction of the nasal (restore alignment of a broken nasal bone), and septal fracture, and evacuation of the septal hematoma (removal of collected blood in the nose. According to the admission record, Patient 1 was an 83-year old male who was admitted to the facility?s secured (locked) unit on XXXXXXX, with diagnoses that included Alzheimer?s dementia (brain disorder that slowly destroys memory and thinking skills), myocardial infarction (heart attack), Parkinson?s disease (disorder of the central nervous system which leads to progressive deterioration of motor function) and depression. The Minimum Data Set (MDS, an assessment and screening tool), dated January 27, 2011, indicated Patient 1 was moderately impaired in his cognitive skills for daily decision-making, had clear speech, and he was able to make himself sometimes understood, and to sometimes understand others. The assessment further indicated Patient 1 required limited assistance from the nursing staff with bed mobility, transfer and walking in his room or in the corridor and his mode of mobility was wheelchair or the walker and his mood appeared down, depressed or hopeless. According to the clinical record , Patient 2 was admitted to the facility?s secured unit on XXXXXXX, with diagnoses that included advanced Alzheimer?s disease, and aphasia (communication disorder from damage to parts of the brain that contain language), dementia and Bi-polar disorder. Patient 2 was Patient 1?s roommate. A review of the physician?s order dated May 6, 2010, indicated to administer Neurontin 200 milligrams (mg.) by mouth when necessary (prn) for anxiety or restlessness. Common psychiatric uses of Neurontin include bipolar disorder, anxiety disorders, insomnia, alcohol detox, and cocaine addiction. The Minimum Data Set (MDS, an assessment and screening tool), dated November 19, 2010, indicated Patient 2 was moderately impaired in cognitive skills for daily decision-making, had unclear speech and sometimes understood others, and sometimes was able to make himself understood, was able to ambulate without a mobility device and wandered daily within the secured unit?s hallway. A review of the Medication Administration Record (MAR) Nurse?s PRN Notes/Medication notes dated March 1, 2011, indicated Patient 2 was administered Neurontin 200 milligrams at 6 p.m. which was effective after 30 minutes, for restlessness, manifested by walking up and down in the hallway and attempting to open an exit door at 6 p.m. A review of the licensed nurse progress notes dated March 5, 2011, at 1:00 a.m., indicated Patient 2 came out of his room and started pacing through the hallway, walking toward the exit door and started shaking the handles of the exit door of the unit. Patient 2 was encouraged to return to bed, but the patient was verbally resistive to staff. The resident looked at the clock and proceeded to return to his room after about five minutes. There was no documented evidence the nursing staff made attempts to calm the resident or ascertain the reason for his current behavior or made an attempt to administer Neurontin for anxiety and restlessness as ordered by the physician as done on March 1, 2011 when the resident exhibited the same behavior. Further review of the licensed nurse progress notes indicated (two and one half hours later) Patient 2 came back out of this room and starting pacing through the hallway and proceeded toward the exit door and shook the exit door handles again. Patient 2 was encouraged to return to bed, but Patient 2 was still resistive to staff verbally and was unable to exit so he went back into his room. There was no documented evidence the nursing staff made attempts to calm the resident or ascertain the reason for his current behavior or an attempt to administer Neurontin for anxiety as ordered by the physician as done on March 1, 2011, when the resident exhibited the same behavior. According to the licensed nurse notes at 3:40 a.m., Patient 2 was found standing at the bedside of Patient 1 hitting him in the face. When the nurse asked Patient 2 what happened he was verbally incoherent and unable to express himself clearly, but was observed with facial grimacing, fist balled up, pacing the hallway and saying, ?No, No? when approached and refused Neurontin and spat it out of his mouth, at which time the physician was notified. During an interview on March 24, 2011, at 7 a.m., with certified nursing assistant (CNA 1) who was on duty and worked on March 5, 2011, on the 11 p.m. to 7 a.m. shift, the day of the incident, she stated at the beginning of the shift she made rounds to her assigned patients? rooms, and both Patients 1 and Patient 2 who were roommates, were asleep. On the night of the incident she saw Patient 2 come out of his room and go to the exit door and began shaking the door. Then Patient 2 looked at the clock and went back to his room. CNA 1 stated around 3:30 a.m., Patient 2 came out of his room again went to the exit door and started shaking the door again, then went back to his room. CNA 1 stated then five minutes later she heard a noise out of Patient 1 and Patient 2?s room. CNA 1 stated she rushed into the room and saw Patient 2 standing over the bed of Patient 1 hitting Patient 1 in the face with both hands. CNA 1 stated she ran over to Patient 1?s bed and pushed Patient 2 back and asked Patient 2 what was he doing and told him to go to his bed. CNA 1 stated she looked at Patient 1 and asked him are you okay and Patient 1 stated ?No.? CNA 1 stated she saw blood all over Patient 1?s face and she yelled for help. Licensed vocational nurse (LVN 1) came to the room and saw what happened and CNA 1 stated Patient 1?s face was full of blood as well as Patient 2?s hands. LVN 1 called the registered nurse supervisor (RNS), and then came back into the room with an ice pack for Patient 1. CNA 1 stated she saw the security guard watching Patient 2. During an interview on March 25, 2011, at 6 a.m., with LVN 1 he stated on March 5, 2011, on the 11 p.m., to 7 a.m., shift, Patient 2 was observed pacing the hallway from 1 a.m., to 3 a.m. Then walked into the patients? recreation room and sat down and came out and paced the hallway again. LVN 1 stated on March 5, 2011, at 3:40 a.m., CNA 1 yelled from Patient 1?s and Patient 2?s room who were roommates. LVN 1 stated he went into the room and took Patient 2 out of the room. Patient 1?s face was bleeding and had blood all over his face. LVN 1 stated he asked Patient 1 ?Are you okay?? and Patient 1 stated ?What is going on?? The RNs arrived onto the unit and assessed Patient 1. LVN 1 stated he then assessed Patient 2 and Patient 2?s speech was incoherent and he began pacing back and forth down the hallway. LVN 1 stated he called 911 (emergency number) and the RNS notified the patients? responsible party and the patients? physicians were notified. LVN 1 stated he did not notify Patient 2?s physician regarding Patient?2?s behavior of pacing the hallway and shaking the locked unit door before the incident happened. A review of the Consultation Report obtained from the GACH dated March 6, 2011, indicated Patient 1 was beaten by his roommate very badly many, many times on the face, ear, nose and eyes, and sustained multiple lacerations (cuts) and a broken nose and the right orbital (eye) wall. Patient 1?s facial Computed Tomography showed acute (new) nondisplaced fracture of the anterior (front), and posterior (back) wall of the right maxillary sinus and acute fracture of the nasal septum bone. The notes indicated the patient could not open his right eye, there was edema (swelling) in the orbital area, ecchymosis (discoloration of the skin, resulting from bleeding underneath) around the eye and on the face, with several small lacerations. Patient 1 had pain in the eye and there was subconjunctival hemorrhage (a burst blood vessel in the eye) and unequal pupils. Patient 1 was admitted to the hospital with diagnoses of nasal fracture secondary to assault/head trauma. A review of the GACH?s Operative Report procedure dated March 14, 2011, indicated Patient 1 underwent the following: 1. Exploration and repair of the right orbital blowout fracture (bones surrounding the eye) with alloplastic (synthetic nasal) implant. 2. Closed reduction of the nasal (restore alignment of a broken nasal bone), and septal fracture. 3. Evacuation of the septal hematoma (removal of collected blood in the nose). The facility?s undated policy and procedures titled, ?Policy on Patient Abuse and Mistreatment?, indicated the facility shall uphold resident?s rights to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntarily seclusion. The policy further notes residents with possible needs and potential for behavioral symptoms and manifestations that may lead to conflict and anger or neglect shall be identified through comprehensive assessments, initially upon a resident?s admission and continuously thereafter, as deemed appropriate and necessary. Those residents identified to have behavioral symptoms potential for conflict and anger shall be monitored in accordance with plans of care developed to address such problems. Monitoring of such residents shall be the responsibility of, but not limited to direct caregivers, Charge nurses, Nursing Supervisors and members of the interdisciplinary team. The facility failed to assess Patient 2 who was pacing in the hallway for two hours, and shaking the exit door handle two times as a sign and symptom of anxiety and restlessness, and to administer the Neurontin medication as ordered by the physician and promptly notify the attending physician of Patient 2?s anxiety, agitation and restlessness. Patient 2 assaulted his roommate Patient 1, resulting in Resident 1 sustaining facial fractures and hospitalization from his injuries. The above violations presented either imminent danger that serious harm would result, or a substantial probability that serious physical harm would result to Patient 1. |
| 910000006 |
SeaPort 17th Care Center |
910012746 |
B |
10-Nov-16 |
BBGT11 |
7889 |
F323 CFR 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 September 19, 2016, at 1 p.m. during a recertification survey Resident 1 was observed walking alone outside of the facility in the alley, near a busy street, alone without any staff?s supervision.
Based on observation, interview and record review, the facility failed to implement its elopement policy and procedures by failing to:
1. Ensure Resident 1 who was diagnosed with dementia, history of falls, wandering disease, hallucinations and delusions, was provided with adequate supervision to prevent her from wandering outside of the facility which was located near an alley and a busy street.
2. Ensure Resident 1 was continuously monitored and visually checked by the nursing staff, activity staff, and the receptionist as often as possible every shift, to prevent any attempts to leave the facility.
3. Ensure Resident 1 was kept safe by closing the entrance/exit doors to prevent resident from attempting to get out of the facility.
4. Ensure Resident 1?s behavior of wandering and elopement episodes of getting out of the facility was documented on the license nurse's weekly progress notes.
During an observation, on September 20, 2016 at 1:30 p.m., Resident 1 who was alone walked out of the facility located close to a busy main street. At the same time, the facility's Maintenance Supervisor 1 who was rolling his equipment across the street for storage saw Resident 1 and redirected her back to the facility.
During an observation, on September 23, 2016, at 1:40 p.m., Resident 1 walked out of the facility alone and walked outside to the corner of the nearby busy main street. The staff did not notice Resident 1 had left the facility and did not provide redirection. The resident returned to the facility without any staff?s supervision.
A review of the clinical records indicated Resident 1 was readmitted to the facility, dated XXXXXXX 2012 with diagnoses of osteoporosis (a condition in which the bones become weak and brittle), dementia (a group of thinking and social symptoms that interferes with daily functioning), and wandering diseases (in people with dementia, is a common behavior that can cause great risk for the person, and is often the major priority and concern for caregivers).
A review of the elopement assessment form (an assessment used to describe an incident where a person with dementia leaves a safe area which typically involves leaving the home or facility in which they live), dated March 27, 2015 indicated Resident 1's clinical condition included dementia, psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), and major depression (a brain disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). The assessment form further indicated the resident was ambulatory, exhibited intermittent confusion but was responsive to redirection and or cueing, had more than 120 days without having any elopement incident but had two behavior of elopement episode in the last six months.
A review of a care plan, dated November 20, 2015 indicated Resident 1 had behavioral problems. The resident had several attempts at getting out of the facility on the following dates; September 19, 2013; October 1, 2013 and December 14, 2013. The care plan indicated the resident was wandering around the facility, was at high risk for unsafe and still exhibited unsafe elopement. The goals included for the resident to have fewer than three episodes of problem behaviors per week, and to remain safe in the facility daily. The intervention included the following: nursing staff continue to visually check on the resident as often as possible every shift to know resident whereabouts, activity staff and the receptionist do visual checks and alert nursing staff if resident was observed attempting to leave the facility, facility staff will check all entrance/exit doors to ensure they are closed to prevent resident from attempting to get out of the facility, and to monitor episodes of attempts at getting out of the facility by documenting the attempts on the license nurse's weekly progress notes.
The Minimum Data Set (MDS, an assessment and care screening tool), dated July 8, 2016 indicated Resident 2 was cognitively intact, required supervision in all activity of daily living, had hallucinations, delusions and wandering behavior.
During an interview with the Director of Nursing (DON) dated September 20, 2016 at 3:15 p.m., stated they did not update the care plan for Resident 1. The DON further stated the resident exhibited behaviors of going out of the facility but there was no one monitoring the resident, and the facility could not limit her going out into the alley.
During an interview with Administrator on September 20, 2016, at 4:05 p.m., stated Resident 1 was able to go out when she wanted to and there was nothing the facility could do about it.
During an interview with DON on September 20, 2016, at 4:50 p.m., stated she did not know the number of episodes as to when and how Resident 1 was wandering outside the facility.
During an interview with DON on September 27, 2016, at 5:10 pm., stated the primary care physician said it was okay for Resident 1 to go out of the facility.
During an interview with Administrator on September 27, at 5:30 p.m., stated the facility tried again with the wander guard system (alarm installed at exit doors to alert the staff about the wandering residents attempting to leave the facility) but the physician did not want to order it.
During a general observation from September 19, 2016 to September 26, 2016 the wander guard system at the back door was disconnected. At the time of the observation the facility stated the wander guard was not working for about 2 years.
The facility's policy and procedure titled "Elopement," dated September 2006 indicated the facility shall provide guidance to staff when residents unexpectedly leave the facility grounds so the staff may locate the resident quickly and have the resident returned safely.
Another policy and procedure titled, "Policy & Procedure for One on One Monitoring," dated September 2016 indicated when a resident is at risk of elopement based on the elopement risk assessment the facility shall provide one on one staff on all shifts and will not be assigned to any resident but to the high risk resident only. The staff shall be relieved by the receptionist who is in the facility (7:00 a. m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m.) and charge nurse during breaks.
The facility?s failed to implement its elopement policy and procedures by failing to:
1. Ensure Resident 1 who was diagnosed with dementia, history of falls, wandering disease, hallucinations and delusions, was provided with adequate supervision to prevent her from wandering outside of the facility which was located near an alley and a busy street.
2. Ensure Resident 1 was continuously monitored and visually checked by the nursing staff, activity staff, and the receptionist as often as possible every shift, to prevent any attempts to leave the facility.
3. Ensure Resident 1 was kept safe by closing the entrance/exit doors to prevent resident from attempting to get out of the facility.
4. Ensure Resident 1?s behavior of wandering and elopement episodes of getting out of the facility was documented on the license nurse's weekly progress notes.
These violations had a direct or immediate relationship to the health, safety, and security of Resident 1.
3 |
| 920000011 |
SAN FERNANDO POST ACUTE HOSPITAL |
920008624 |
A |
18-Jun-13 |
OFFW11 |
14732 |
CFR 42 ?483.25 Quality of Care - F309 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. On January 3, 2011, the Department received a complaint alleging a resident (Resident 1), who was developmentally disabled (inability to function normally, physically or mentally; incapacitated) was transferred to a general acute care hospital (GACH) on December 27, 2010, due to retention of urine. At the GACH, the resident was catheterized (a tube inserted into a patient's bladder via the urethra which allows urine to drain freely from the bladder) which released 2400 cubic centimeters (cc). The complaint alleges the resident was diagnosed with obstructive renal failure, possibly with permanent damage, and was hospitalized in the intensive care unit. On January 18, 2011, an unannounced visit was made to the facility to investigate this allegation. Based on interview and record review, the facility failed to provide the necessary care and services when Resident 1, who was continent (control of the elimination of urine from the bladder) of urine and became incontinent (involuntary urination/inability to control) of urine and his condition started to deteriorate by not: 1. Completing the bladder assessment and assessing Resident 1?s urination output for two days, when there was a change in urination patterns. 2. Monitoring the resident?s fluid intake and output which included quantification of the urine as indicated in the resident?s plan of care and the facility?s policy. 3. Physically and continually assessing the resident for urinary retention after the resident?s urinary condition changed. 4. Notifying the physician to obtain an order for intermittent catheterization (a method for draining urine from a bladder in intervals). 5. Immediately transferring the resident to the hospital after the physician ordered a transfer to the GACH. These failures resulted in Resident 1 not receiving the necessary care and services when there was a change in condition manifested by urinary retention, abnormal blood work, change in vital signs with an elevated blood pressure, heart rate, and an elevated respiratory rate with low oxygen saturation, requiring mechanical ventilation. As a result, Resident 1 was transferred to a GACH and admitted to the intensive care unit (ICU) for two days and was diagnosed with obstructive acute renal failure (occurs when the blood supply to the kidneys is suddenly interrupted or when the kidneys become overloaded with toxins), pulmonary edema (a condition caused by an excess fluid in the lungs, making it difficult to breathe) and with possible pneumonia (an inflammatory condition of the lung) and, requiring antibiotics. On January 18, 2011, a review of Resident 1?s record indicated the resident was a 53 year-old developmentally disabled male admitted to the facility on December 23, 2010. The resident?s diagnoses included respiratory failure (inadequate gas exchange by the respiratory system) with a tracheostomy (an opening in the trachea for the insertion of a catheter or tube to facilitate breathing), morbid obesity (50-100% or 100 pounds above their ideal body weight), diabetes mellitus (group of metabolic diseases in which a person has high blood sugar), and sleep apnea (characterized by abnormal pauses in breathing or instances of abnormally low breathing during sleep).A review of the Hydration Risk and Malnutrition Risk Assessments, dated December 23, 2010, indicated the resident had risk factors for dehydration (excessive loss of body water) due to a decline in activities of daily living (ADL), diabetes, infectious process, use of medications such as potassium and cardiovascular agents, and the resident?s daily fluid requirement was in a range of 1000-2000 cc.According to the Bladder Incontinence Evaluation Assessment, dated December 23, 2010, the resident was alert, oriented, continent of bladder and used a urinal at the bedside. However, on the facility's standard Bladder Assessment Form, eight assessment areas on the form, Numbers 3-for Voiding Pattern; 4-Bladder Continence Scale; 5-Associated Symptoms; 6-Relief after Voiding; 7 Bladder Distention; 8 Bladder Distention; 9-Pattern of Fluid Intake; and 11-Environmental Factors were not completed by the licensed nursing staff. The licensed nursing staff did not assess the resident for pertinent bladder status in order to develop a plan of care appropriate to recognize the problem of urinary retention and intervene timely. A review of the Sub-Acute Licensed Nurse Progress Notes, dated December 23, 24, and 25, 2010, indicated the resident was continent of urine with clear yellow urine output. However, the intake and output (I&O) records from December 23-25, 2010, did not indicate the volume of urine output during each void including the total 24-hour urine totals as stipulated in the facility?s policy. According to the progress notes, on December 26 and 27, 2010, the resident was incontinent of urine and was not assessed to identify the nature and the reason of his incontinence. A plan of care was not initiated to closely monitor the resident?s urine output.Resident 1?s I/O record from December 23- 27, 2010, did not indicate the daily volume of urine output. On December 23, 2010, on the day the resident was admitted to the facility, his fluid intake during the 7 p.m. to 7 a.m. shift was 400 cc. The urine output record indicated the resident urinated once; the volume of the urine output was not quantified. On December 24, 2010, the resident?s 24-hour fluid intake was 1200 cc, but the 24-hour urine output record indicated the resident urinated four times without the amounts. On December 25, 2010, the 24-hour fluid intake was 1000 cc and the 24-hour urine output record indicated the resident urinated twice without an amount. On December 26, 2010, the 24-hour fluid intake was 1000 cc and the 24-hour urine output record indicated the resident urinated four times without a volume amount. On December 27, 2010, the resident?s fluid intake from 7 a.m. to 7 p.m. was 615 cc; during the same 12 hours period, the record indicated the resident only urinated once without a volume amount. The staff failed to follow the facility?s policy in monitoring urine output for assessment of adequate fluid balance. According to the licensed nurse's note, dated December 26, 2010, and timed at 2:15 p.m., the resident had altered vital signs and oxygen saturation level. The resident had an elevated blood pressure of 144/94 (reference range 120/80 mm/Hg) increased heart rate of 109 beats per minute (reference range 60-100) increase respiration of 26 per minute (reference range 12-20 breaths per minute and a low oxygen saturation level of 85 percent (normal on room air=97-100%). There was no temperature recorded. The respiratory therapist was notified and oxygen at 15 liters per minute was administered via tracheostomy. On December 26, 2010, at 2:15 p.m., the physician was also notified of the resident's change of condition and orders were obtained. At 2:30 p.m., the resident was placed on a ventilator (mechanically assisted breathing) via the tracheostomy and the physician ordered a basic metabolic panel (BMP/that tests glucose, calcium, sodium, potassium, carbon dioxide, chloride, blood-urea-nitrogen [BUN], and creatinine) blood work to be drawn. While the resident?s condition continued to deteriorate, manifested by abnormal vital signs, and requiring mechanical ventilation, there was no documented evidence the licensed nurses had assessed the resident's urinary status and/or assessed the resident's lower abdomen to check for clinical signs for urinary retention such as discomfort, inability to void, and distention of the lower abdomen for possible need for catheterization to prevent further complication. According to a laboratory report, dated December 21, 2010 and timed at 4:55 a.m., two days prior to the resident?s admission, the resident?s Blood-Urea-Nitrogen (BUN) level was within normal at 9 mg/dL (normal reference range=7-18 mg/dL) and creatinine serum was also within normal at .8 mg/dL (normal reference range=.6-1.3 mg/dL). However, after Resident 1 had a change in condition the physician ordered laboratory work, and the results, dated December 27, 2010, and timed at 1:30 p.m., indicated an elevated BUN (the waste product filtered out of the blood by the kidneys; conditions that affect the kidney have the potential to affect the amount of urea in the blood) level of 59 mg/dl (reference range 7-23 mg/dl); an elevated Creatinine ([Cr]waste product produced in the muscles; filtered out of the blood by the kidneys, blood levels which are a good indication of how well the kidneys are working) level of 7.3 (reference range 0.6-1.4 mg/dl) and a low serum sodium (vital to normal body processes, including nerve and muscle function) level of 129 (reference range=135-145 milliequivalent /liter/mEq/L). A low serum sodium, elevated BUN and Cr levels are indicators for renal (kidney) disease (Stephen Bartlett, RD et al Nutrition Handbook, Pages 32-34).According to a Licensed Nurse?s Progress note, dated December 27, 2010, and timed at 1:30 p.m., the abnormal laboratory results were reported to the physician. On the same day, at 6:20 p.m., an order to transfer the resident to the GACH was obtained from the physician. The note indicated at 6:50 p.m., an ambulance service was called to transport the resident to the GACH. However, the resident was not picked up until 10 p.m., which was more than three hours later.In addition, on December 27, 2010, from 7 pm. until the resident was transferred to the GACH at 10 p.m., there was no documented evidence Resident 1?s fluid intake and urine output were being monitored. On January 18, 2011 at 2:50 p.m., during an interview, the director of nurses (DON) stated, after he was shown Resident 1?s I & O record without urine output amount, that he had given an in-service training to the staff regarding dehydration and the importance of recording intake and output in cubic centimeters.On January 20, 2011, a review of the GACH/Emergency Room record, dated December 28, 2010, indicated an indwelling urinary catheter (Foley) was inserted and two liters (2000 cc) of urine was evacuated from Resident 1?s bladder. The resident was diagnosed as having obstructive acute renal failure (a sudden decrease in renal function, which if uncorrected, can lead to irreversible tubular necrosis, one of the causes is obstruction of urine flow) and was admitted to the ICU on December 28, 2010. An Article, titled, ?Your Urinary System and How it Works? written by the National Institutes of Health (NIH), indicated although the urinary bladder may hold as much as 600 ml of urine, the desire to urinate is usually experienced when it contains about 150 ml. According to the article an acute urinary retention is a medical emergency requiring prompt action. Chronic urinary retention may not seem life threatening, but it can lead to serious problems and should also receive attention from a health professional (http://kidney.niddk.nih.gov/kudiseases/pubs/yoururinary/)Resident 1 had accumulated and retained urine in the bladder while in the sub-acute facility in an excess of 2000 cc, as evidenced by the two liters of urine evacuated from the resident?s bladder in the GACH, which was beyond the normal capacity of the bladder. The sub-acute licensed nursing staff did not conduct an assessment and monitoring of the resident's voiding (urination) patterns by means of an I & O record which would indicate the volume of urine being retained in order to identify urinary problems and intervene before the problem progressed to acute renal failure as stated in the facility's policy and procedures. According to the sub-acute facility's policy, dated March 1, 2008, and titled, "Intake and Output," the facility will maintain an intake and output record to monitor residents for adequate fluid balance. Weekly assessment will be done to determine hydration and ongoing need for the I & O monitoring. It further stipulated fluids should be documented in cc on the I & O sheet on each shift. Intake for a twenty-four hour period should be totaled each day and deficiencies in fluid intake or fluid balance will be reported to the physician and recorded in the residents' clinical records and care plans will be updated.A review of a Renal Consultation report from the GACH, dated December 28, 2010, indicated the resident had evidence of obstruction in the bladder with a complaint of bladder fullness, probably from the prostate, which was relieved with an indwelling urinary catheter placement. The Consultation Note indicated during the empting of the bladder, the catheter was clamped a couple of times to prevent adverse effects from a rapid bladder emptying. The resident stated he felt a little better after the removal of urine and the initial lab results indicated acute renal failure. According to the consultation note, Resident 1 was admitted to the hospital for further evaluation.A review of the resident?s laboratory tests done at the GACH, dated December 29, 2010, indicated the resident?s BUN remained elevated at 45 mg/dL (reference range 7-18 mg/dL) and the Cr level remained elevated at 2.1 mg/dL (reference range 0.6-1.3).The sub-acute licensed nursing staff failed to assess Resident 1 and detect the accumulation and retention (the inability to completely empty the urinary bladder by micturition/voiding) of urine beyond the normal capacity of his bladder that resulted in obstructive acute renal failure by not: 1. Completing the bladder assessment and assessing Resident 1?s urination output for two days, when there was a change in urination patterns. 2. Monitoring the resident?s fluid intake and output which included quantification of the urine as indicated in the president?s plan of care and the facility?s policy. 3. Physically and continually assessing the resident for urinary retention after the resident?s urinary condition changed. 4. Notifying the physician to obtain an order for intermittent catheterization (a method for draining urine from a bladder in intervals). 5. Immediately transferring the resident to the hospital after the physician order a transfer to the GACH. The above violation presented an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would and did occur to Resident 1. |
| 920000053 |
Santa Clarita Post-Acute Care Center |
920008996 |
A |
29-Feb-12 |
LOI511 |
14289 |
Title 22 Section 72311 (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited.Based on interview and record review, the facility failed to provide treatment to manage a patient's behavior associated with the acquiring and self-administration of an illegal substance (heroin) while in the facility that resulted in recurrent loss of consciousness and heroin toxicity by failing to: Conduct a comprehensive assessment and develop a plan of care with effective and useful interventions in the management of the patient's behavior related to known drug-abuse tendencies. The Department received a complaint alleging the overdose of a patient. An unannounced complaint investigation was conducted during the annual Recertification survey. On August 4, 2011, a review of the admission record indicated Patient 16 was first admitted to the facility on May 10, 2011, with diagnoses that included smoker, depression, and psychosis. He was readmitted on June 1, 2011, with additional diagnoses that included polysubstance dependence. The Diagnostic Interview, Mental and Behavioral Note visit form dated June 3, 2011, indicated the resident had maladaptive behaviors that included setting fire to his mobile home after having a blackout from taking a "bunch" of medications. Management recommendations to be considered included follow-up with appropriate support regarding his substance dependence. A plan of care initiated on June 8, 2011, indicated the patient was at risk for alteration in comfort due to diagnoses of depression, anxiety, and psychosis. The care plan had a goal that stated the patient would have adequate comfort evidenced by relaxed body posture, facial expression, and verbal expression of comfort for 90 days. The interventions on the plan of care included to monitor adverse reactions and notify the physician if there was a change in level of consciousness, and to monitor the vital signs.The Minimum Data Set [(MDS) - a standardized comprehensive assessment of the patient's problems and conditions] dated June 14, 2011, indicated the patient was able to make himself understood and had the ability to understand others, had intact cognitive skills for daily decision-making, required supervision with eating and personal hygiene, limited assistance with transfers and dressing, and extensive assistance with bathing. The MDS also indicated the patient manifested behavior of rejecting care 1 to 3 days during the prior seven days. The Care Area Assessment had "behavior" triggered as a health concern, indicating the need for a plan of care that focused on the patient's safety, and to identify areas in which staff interventions might be useful in controlling behavior. Following the completion of the MDS, the licensed staff did not utilize the information available to them when developing a plan of care with interventions to address the patient's diagnosis of and actions associated with polysubstance dependence, and/or assess the facility's ability to provide care and manage the behaviors associated with polysubstance abuse. A review of the Licensed Personnel Weekly Progress Notes revealed that on June 15, 2011, at 1 p.m., Patient 16 was allowed to go out of the facility on pass from 12:15 p.m. to 3:10 p.m. According to the " Release of Responsibility for Out on Pass/Leave of Absence " form, the patient was in a stable condition when he left the facility with his friend. The patient had a physician's order allowing him to leave the facility on pass, and had previously been out on pass on seven prior occasions from May 18, to July 13, 2011.First Incident: A review of the Licensed Personnel Weekly Progress Notes dated June 16, 2011 at 12:55 p.m., revealed a certified nursing assistant (unidentified) informed the charge nurse that Patient 16 was found in his room unresponsive. The charge nurse noted the patient was lying in bed with his eyes fixed, pupils pin point, skin warm and dry to touch, bluish color to the face, positive carotid pulse, but not responsive to tactile stimuli. The paramedics were called and the patient was transferred to the general acute care hospital (GACH) emergency department (ED) at 1:15 p.m. The physician was notified. A review of the ED report obtained from the GACH dated June 16, 2011, indicated the patient was brought to the ED due to an altered mental status. The record indicated the patient had a history of drug abuse, with possible unobserved narcotic ingestion as the reason for his altered mental status, and a narcotic overdose. The GACH toxicology screen report dated June 16, 2011, indicated the patient was positive for opiates from possible narcotic overdose. He was hospitalized until discharged to the facility on June 20, 2011 at 3 p.m. Second Incident: According to the Licensed Personnel Weekly Progress Notes admission note dated June 20, 2011, at 4 p.m., approximately one hour after the patient was readmitted from the GACH to the facility via gurney, he was found in his room for the second time unresponsive. The vital signs were: blood pressure 96/58 millimeters of mercury (mm Hg), pulse was 76 beats per minute, respirations were 14 breaths per minute, and oxygen saturation on room air was 82 percent (%). A saturation of 97% of the total amount of hemoglobin in the body is filled with oxygen molecules. A range of 97% to 99% is generally considered normal on room air. Anything below 90% could quickly lead to life-threatening complications. The margin between "healthy" saturation levels (95-98%) and respiratory failure (usually 85-90%) is narrow. (American Journal of Nursing: June 2009 - Volume 109 - No.6, pages 52-59). The Licensed Personnel Weekly Progress Notes indicated the physician was notified and he gave orders to transfer the patient to the GACH emergency department (ED) for further evaluation. The patient was transported to the ED via paramedics on the same day. The Licensed Personnel Weekly Progress Notes revealed the patient was discharged from the GACH, and readmitted to the facility on June 21, 2011, at 2:30 a.m. The admission note indicated the patient arrived at the facility via taxi and ambulatory by himself. According to the Patient Instruction form, the patient was issued patient instructions informing him that the use of heroin (street drugs) is illegal in the United States.A review of the Licensed Personnel Weekly Progress Notes dated June 21, 2011, sometime after 6 p.m. (no time indicated), revealed a Certified Nursing Assistant (CNA) reported to the charge nurse that there was something inside the patient's right sock. The charge nurse found a small plastic bag containing a syringe, a spoon, and a very dark-in-color sticky substance. The note also indicated the Director of Nursing (DON) and the physician were notified, and the patient was to be monitored closely.Following the June 21, 2011, readmission, the licensed nursing staff did not develop a plan of care utilizing the information contained in the five pages of Patient Instructions to prevent similar events associated with the patient's actions surrounding the use of illegal controlled substances while in the facility. These instructions were filed in the patient's clinical record. There was no indication that the Interdisciplinary Team was involved with the decision-making to prevent Patient 16's drug-seeking behaviors. In addition, the facility did not attempt to find the patient's source providing the illegal drugs in order to protect Patient 16 and all other patients from accessing the drugs.On August 4, 2011, at approximately 7:25 p.m., during an interview with the DON, in the presence of the Social Services Designee and the MDS coordinator, the DON stated the facility had not incorporated Patient 16's repeated drug-seeking behaviors in the care plan, but should have. It was stated that the care plan should have included interventions to protect Patient 16 and any other patients in the facility that had the potential to be affected, from illegal drugs.During an interview on August 22, 2011 at 2:10 p.m., the DON stated, after finding the items in Patient 16's sock, on June 21, 2011, she gave the staff instructions to notify the physician and to monitor the patient closely when he was readmitted on June 21, 2011. According to the DON she did not speak to the patient about the substance found in his sock, but did speak to the patient's friend, who stated she did not have any idea what the unknown substance was. The DON stated she instructed the staff members to closely watch any visitors who came to visit the patient and to ensure they signed in and out.On July 22, and 28, 2011, the physician ordered for the patient to be scheduled for a total of seven Methadone maintenance treatments at the Mental Health Clinic (clinic) on July 26, 29, 30, and 31, 2011, and August 1, 2, 3, 2011.Methadone is a drug used in approved methadone maintenance programs, which can substitute for heroin, or other illicit narcotics in persons who want to terminate a drug use. Lippincott's Nursing Drug Guide, 2003, p. 767. A review of the care plans revealed the licensed staff did not develop a plan of care related to the Methadone treatment program. According to the Licensed Personnel Weekly Progress Notes dated July 26, 2011, at 2 p.m., the scheduled Methadone treatment was missed for unknown reasons and another appointment was rescheduled for July 28, 2011. There was no note dated July 29, 2011, to indicate that the patient attended his appointment as scheduled for the day. There was no note in the social service notes to address this appointment.While the third Methadone treatment scheduled for July 31, 2011, was pending, the patient had another incident of illegal drug consumption that resulted in an altered mental status and admission to the GACH on July 31, 2011. Third Incident: A review of the Licensed Personnel Weekly Progress Notes dated July 31, 2011 at 7 a.m., revealed the patient was found in his room with an altered mental status, with vital signs of: blood pressure 110/65, heart rate of 86 beats per minute, respiratory rate of 18 breaths per minute, temperature 98.2 degrees Fahrenheit, and oxygen saturation of 85%. The patient was transferred by paramedics to the GACH emergency room (ER). A review of the ER Report dated July 31, 2011, revealed the patient was found with an altered mental status at the nursing home. Paramedics administered Narcan 2 milligrams, and his mental status improved dramatically. According to the report, the patient admitted using heroin the morning of July 31, 2011. The patient was unable to provide medical history details due to his altered mental status from the narcotic overdose. The ER documentation reflected the patient was intermittently somnolent (sleepy, drowsy), and had PVC [(premature ventricular contractions) a heart condition]. According to the History and Physical (H&P) dated July 31, 2011, from the GACH, Patient 16 was a heroin addict, and admitted to using heroin while in the facility. When asked how (he acquired the drugs), he said that he had family members sneak them in to him. He stated he had been on heroin for many years. According to the H&P, one of the diagnoses was heroin toxicity. According to a Physician's Progress Note dated July 31, 2011, Patient 16 was admitted to the hospital Telemetry Unit (a unit where patients with heart conditions are observed and treated) with the diagnosis of an altered mental status secondary to narcotic overdose. The patient was discharged back to the skilled nursing facility on August 1, 2011.A review of the Licensed Personnel Weekly Progress Notes dated August 1, 2011, (no time) revealed Patient 16 was readmitted with diagnoses that included heroin abuse and psychiatric disorder.After the readmission of Patient 16 from the GACH after displaying drug-seeking behaviors that resulted in three incidents of altered mental status secondary to heroin abuse, the licensed nursing staff did not utilize critical existing information to develop a plan of care with specific interventions to address the drug-seeking needs and behaviors of Patient 16 to protect him while under their care. The treatment plan that was supposed to be in place was not implemented as ordered by the physician. On August 4, 2011 at 5:05 p.m., during an interview, the patient provided the following information: He admitted having a substance abuse problem and an addiction to heroin. When asked how he obtained the drugs in the facility, he stated that a person (he would not identify) would come to visit him, would not sign in at the front desk, and would deliver the heroin to him. He said the syringe and needles were brought into the facility hidden in his socks. The patient stated he self-administered the drugs in the bathroom in his room, which was convenient for him to self-administer the drugs and remain unnoticed by the facility staff members.On August 4, 2011 at 7:20 p.m. during an interview with the DON regarding the patient's three incidents of drug overdose on June 16, 2011, June 20, 2011, and July 31, 2011, she stated the facility should have done a thorough investigation. The DON could not provide documented evidence that a comprehensive plan of care had been developed with interventions to prevent the patient's recurrent self-administering of heroin. The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Patient 16. |
| 920000075 |
STUDIO CITY REHABILITATION CENTER |
920009222 |
B |
11-Apr-12 |
ERVG11 |
4015 |
72543(f) Patients' Health Records (f) Patients' health records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each patient. Such records shall be filed and maintained in accordance with these requirements and shall be available for review by the Department. All entries in the health record shall be authenticated with the date, name, and title of the persons making the entry.Based on observation, interview, and record review, the facility failed to maintain Patient 1?s closed medical records in accordance with accepted professional standards and practices by failing to: 1. Ensure the closed medical record was filed and kept in safe and proper storage as stated in the facility?s policy and procedures. 2. Ensure that the medical record was filed in an accessible manner and was readily available to the Department for review. On March 5, 2012, at 1:50 p.m. during a complaint re-investigation visit, the Department requested the facility?s administrator to provide Patient 1?s closed medical record for review. The Administrator instructed Employees A and B to retrieve the closed record from the medical records department.When the closed record was not made available to the investigator thirty minutes after the record was requested, the Administrator was asked for a second time to make the record available for a review. The Administrator stated the medical record staff members were unable to locate the record and they were still searching.On March 5, 2012 at 2:15 p.m., Employee B and his staff members were observed searching for the record in the basement where medical records were stored. When asked, Employee B stated the last time he saw the record was in May 2011, when it was checked out from storage by the previous Administrator who was no longer employed by the facility. According to Employee B, he did not see the record returned after it was checked out in May of 2011.On March 5, 2012 at 3 p.m., during an interview, the Administrator stated the medical record staff members were unable to locate and retrieve Patient 1?s closed record and would make it available to the Department as soon as it was recovered.According to Employee B, as of March 18, 2012, the patient?s closed medical record could not be located and would not be made available to the Department. The violation also had a potential impact on the security of clinical records for all other patients in the facility. A review of the facility?s policy and procedure titled Record Systems: Storage, Protection and Access, indicated the following: 1. The facility shall safeguard health record information against loss, destruction or unauthorized use. 2. The health information office and the health record storage areas are restricted and only accessible to authorized personnel. 3. Procedures and routine operations included to lock medical records and not to allow unauthorized person(s) to remain in the office without an authorized person present. 4. Store health records in a separate locked storage room, specifically designated of storage, where access is restricted, and controlled. The facility did not implement the above stated policy and procedure to protect the security of the Patient 1?s closed medical record.The facility failed to maintain Patient 1s closed medical record in accordance with accepted professional standards and practices by failing to:1. Ensure the closed medical record was filed and kept in safe and proper storage as stated in the facility?s policy and procedures. 2. Ensure that the medical record was filed in an accessible manner in the facility or in closed health record storage that provided prompt retrieval when needed and was made readily available upon request for review by the Department.The above violation presented a direct relationship to the security of Patient 1?s medical record, and all other patient medical records stored in the facility. |
| 920000092 |
Stoney Point Healthcare Center |
920009224 |
A |
10-Aug-12 |
NZUM11 |
11293 |
Title 22 Section 72311 (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient?s care plan according to the methods indicated. Each patient?s care shall be based on this plan.On August 11, 2010, the Department received an Entity Reported Incident (ERI) that alleged Patient 1 was observed with blood on his face, a lacerated upper eyelid and a swollen left eye. Patient 2 came to the Nurses Station with his fist stained with blood, and stated he was responsible for Patient 1?s injury.On August 19, 2010, at 12:30 p.m., an unannounced visit was made to investigate the above allegation, which revealed Patient 2 assaulted Patient 1 that resulted in injuries including a laceration to the left eyebrow, nasal bone fracture, fractured ribs, and a left pneumothorax (collapsed lung which occurs when air leaks into the space between the lungs and chest wall, creating pressure against the lung). Patient 1 was admitted to the intensive care unit (ICU) of a general acute care hospital (GACH) and was hospitalized from August 9, 2010, to August 16, 2010.Based on interviews and record review, the facility failed to implement Patient 1?s care plan as indicated to prevent injuries when assaulted by Patient 2, who was known to have behavioral problems manifested by sudden outbursts of anger, especially when personal items were involved, by failing to: 1. Implement Patient 1's care plan by monitoring Patient 1?s whereabouts ?frequently? and redirecting him to his room as necessary, to prevent him from wandering into Patient 2?s room, where he was assaulted causing injuries that resulted in seven days of hospitalization.2. Implement Patient 2's care plan that was developed for the patient's behavior of exhibiting episodes of behavioral problems manifested by sudden outbursts of anger by monitoring the patient and re-directing the patient's behavior to something positive.According to the admission record, Patient 1 was a 76-year-old male admitted to the facility on March 11, 2010, with diagnoses that included Alzheimer?s disease (disease which involves progressive impairment in memory, judgment, decision making, orientation to physical surroundings, and language), bipolar disorder (disorder which involved periods of excitability alternating with periods of depression), and depression. The Quarterly Minimum Data Set (MDS-standardized assessment and care screening tool) dated June 6, 2010, indicated the patient had short-term memory impairment, moderately impaired cognitive skills for daily decision-making and was independent with walking, transfers and mobility. The MDS also indicated the patient was assessed as being a wanderer with the frequency of the behavior occurring daily. Patient 1 had a plan of care initiated on March 11, 2010, and updated in June 2010, for bipolar affective disorder, with continuous wandering and recurrent outbursts of anger, severe agitation, and assaultive behavior. The goal was for the patient to be free of injury, with approaches that included redirecting the patient to his room as needed and to monitor the patient?s whereabouts.A review of the nurse?s notes dated August 8, 2010, at 9 p.m., revealed Patient 1 was seen ambulating and had a bloodied face, a laceration to the left upper eyebrow, and swelling to the left eye area. First aid treatment was provided to Patient 1. The physician was notified and paramedics transferred Patient 1 to the acute care hospital on August 8, 2010, at 9:37 p.m. According to the physician?s examination documented on the GACH Physician Clinical Report dated August 8, 2010, Patient 1?s oxygen saturation was 96 on room air and was stable for outpatient management. (Oxygen saturation is an indicator of the percentage of hemoglobin saturated with oxygen at the time of the measurement, with 96 percent to 100 percent considered to be within normal range). Patient 1 was discharged from the GACH emergency department on August 9, 2010. The patient returned to the skilled nursing facility with instructions to return to the emergency department August 10, 2010, if not better.According to the nurse?s notes, Patient 1 returned to the facility on August 9, 2010, at 2:10 a.m. The nurse?s notes indicated that on August 9, 2010, at 8:45 a.m., approximately six hours after Patient 1 was discharged from the GACH emergency room, the facility received a call from the acute care hospital emergency department physician requesting Patient 1 be transferred back to the emergency department for a possible pneumothorax (a collapsed lung). The patient was transferred to the acute care hospital on August 9, 2010, at 9:45 a.m.A review of the Discharge Summary Report dated August 16, 2010, obtained from the GACH, revealed Patient 1 was evaluated in the emergency department for evidence of a left sided pneumothorax, nasal bone fracture, a periorbital ecchymosis (black eye), edema (swelling) bilaterally as well as a laceration to the left eyebrow which was repaired with three sutures. The patient had a chest tube inserted to treat the left sided pneumothorax and was admitted to the intensive care unit (ICU) with a one-to-one sitter because of his increased agitation and aggressive behavior. The patient was stabilized and was discharged to a geropsychiatric unit on August 16, 2010. According to the facility?s investigation, on August 8, 2010, at approximately 9 p.m. during rounds, Patient 1 was ambulating in the hallway and was noted to have blood on his face, a left upper eyelid laceration, and swelling on the lower area of the left eye. The patient stated he must have fallen. Patient 2 came to the nurse?s station (no time indicated) with his fist stained with blood and was interviewed by a licensed nurse who asked what had happened. Patient 2 stated he was responsible for inflicting injury to Patient 1 for stealing his clothing. According to the facility?s interview with Patient 2?s roommate, conducted by Registered Nurse A on August 10, 2010, at approximately 2:05 p.m., he stated Patient 1 came into Patient 2?s room and started screaming and cursing at Patient 2, apparently saying the ?F? word and started hitting Patient 2, at which point Patient 2 started hitting Patient 1.According to the admission record, Patient 2 was a 71 year old male admitted to the facility on March 23, 2010, with diagnoses that included Alzheimer?s disease, hypertension, and seizure disorder. The MDS dated July 5, 2010, indicated Patient 2 had short-term and long-term memory impairment, moderately impaired cognitive skills for daily decision-making, and required supervision with walking and transfers. The MDS also indicated the patient was assessed as exhibiting persistent anger with self or others up to five days a week. Patient 2 had a care plan dated May 13, 2010, for exhibiting episodes of behavioral problems manifested by sudden outbursts of anger and wanting to go home, and had episodes of accusing staff of stealing his clothes, jacket, and medication from his closet. The planned interventions for Patient 2?s behavior included monitoring the patient for the number of behaviors, and re-directing the patient?s behavior to something positive.The goal was for the patient to have less than one to two episodes of behavioral problems daily.On August 19, 2010 at 3 p.m. during an interview, RN A stated Patient 1 was being monitored ?frequently? by the safety nurse.RN A stated safety nurses are trained certified nurse assistants who are responsible to monitor the patients? whereabouts and log their activities on the ?Patient Whereabouts Monitoring Log.? RN A stated one safety nurse is assigned outside on the patio and another safety nurse is assigned inside the facility. However, she was unable to provide documentation on how frequently and at what time Patient 1 was monitored by the safety nurse.A review of the ?Patient Whereabouts Monitoring Logs? provided by RN A revealed Patient 1?s name was not listed on the indoor Patient Whereabouts Monitoring Log indicating Patient 1 was not monitored as stated in the plan of care. During an interview on August 19, 2010 at 3 p.m., RN A confirmed Patient 1 was not listed on the indoor Patient Whereabouts Monitoring Log dated August 8, 2010, but was listed on the Patio Patient Whereabouts Log. The Patio Patient Whereabouts Monitoring Log for August 8, 2010, indicated that Patient 1 was in the courtyard at 12:55 p.m., 2:15 p.m., and at 2:48 p.m. After 2:48 p.m. there was no further documentation about the patient?s whereabouts that day. A review of the Patient Whereabouts Monitoring Log, dated August 8, 2010, did not have Patient 1 listed as a patient to be monitored inside the facility. There were a total of 27 patients to be monitored inside the facility and their whereabouts were documented at 7 a.m., 9 a.m., 11 a.m., 1 p.m., 3 p.m., 5 p.m., 7 p.m., 9 p.m., and 11 p.m.During an interview with Certified Nursing Assistant A (CNA A) on October 7, 2010, at 1:30 p.m., she stated she was the safety nurse who was monitoring the patients inside the facility on August 8, 2010, at the time Patient 1 was assaulted by Patient 2. CNA A stated she monitors all patients in the facility by making rounds throughout the interior of the facility every 20 minutes. She stated she was the only staff member assigned to monitor the 27 patients who required monitoring inside the facility. She stated she was at the nursing station when she noticed Patient 1 entering the main corridor from the exit door north of the nurse?s station at approximately 8:45 p.m.She stated Patient 1 was singing and had blood on his face.The facility?s policy and procedure titled, ?Policy for the Safety Nurse,? (undated), indicated one safety nurse is assigned to the courtyard for the 7 a.m. to 3 p.m. shift, and one is assigned on the 3 p.m. to 11 p.m. shift to monitor patients who stay in the courtyard and document on a monitoring log. The policy indicated a safety nurse is assigned inside the facility?s premises to monitor the patients by checking the rooms and bathrooms with a monitoring log for the 7 a.m. to 3 p.m. shift, and on the 3 p.m. to 11 p.m. shift.The facility failed to implement Patient 1?s care plan as indicated to prevent injuries when assaulted by Patient 2, who was known to have behavioral problems manifested by sudden outbursts of anger, especially when personal items were involved, by failing to:1.Implement Patient 1's care plan by monitoring Patient 1?s whereabouts ?frequently? and redirecting him to his room as necessary, to prevent him from wandering into Patient 2?s room, where he was assaulted causing injuries that resulted in seven days of hospitalization.2. Implement Patient 2's care plan that was developed for the patient's behavior of exhibiting episodes of behavioral problems manifested by sudden outbursts of anger by monitoring the patient and re-directing the patient's behavior to something positive.The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Patient 1. |
| 970000097 |
SKYLINE HEALTHCARE CENTER-LOS ANGELES |
920009740 |
B |
14-Feb-13 |
R9U411 |
8858 |
F323 (Accidents) 42 CFR section 483.25(h) Accidents. The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The Department received a faxed report from a facility staff member that Resident A went missing from the facility between 1:30 ? 1:45 a.m., on October 15, 2012, and could not be located by facility staff. On October 29, 2012, an unannounced complaint investigation was conducted at the facility. Based on observation, interview and record review, the facility failed to: 1.Supervise and monitor Resident A, who had diagnoses that included: difficulty walking, lack of coordination, seizure disorder, hypertension, dysphagia (difficulty swallowing) and wandering behavior. In addition, the resident had previously attempted to leave the facility.The failure to provide adequate supervision and monitoring resulted in Resident A attempting to elope from the facility on September 29, 2012. On October 15, 2012, the resident actually left the facility without the knowledge of facility staff. A review of the facility?s investigation report indicated Resident A attempted to leave the facility but was stopped by the staff on September 29, 2012, at approximately 8 p.m.A review of the facility?s second investigation report indicated Resident Awent missing on October 15, 2012. According to the report, the resident went missing between 1:30 ? 1:45 a.m. and at approximately 2 a.m., Certified Nursing Assistant (CNA) 1 reported to Registered Nurse (RN) 1, that she had not seen Resident A since approximately 1:25 a.m. The Director of Nursing (DON), Administrator, Los Angeles Police Department (LAPD), and a family member were all notified. The report also indicated the facility staff as well as the LAPD all searched for Resident A, however, he could not be found. At approximately 12:30 p.m., the DON received a call from an employee at a local college, who said she found Resident A wandering around the college campus. The DON called the LAPD and they along with a family member went to pick up Resident A from the college and then took him back to the facility. According to MapQuest the distance between the facility and the college where Resident A was found is 2.35 miles. A review of Resident A?s admission information indicated he was readmitted to the facility on September 18, 2012, with diagnoses that included, difficulty walking, lack of coordination, seizure disorder, hypertension and dysphagia (difficulty swallowing) and wandering behavior. The physician?s order, dated September 18, 2012, indicated Resident A was to wear a wander-guard bracelet at all times. The staff was to check for malfunctions every shift. The Minimum Data Set (MDS ? a standardized comprehensive assessment of the resident?s problems and conditions), dated September 25, 2012, indicated the resident had clear speech, usually understands and was usually understood. The MDS also indicated Resident A did not exhibit wandering behavior. However, the physician?s order (above) indicated Resident A was to wear a wander-guard bracelet at all times. The Wandering/Elopement Care Plan, dated September 29, 2012, indicated the Resident A eloped. The interventions included, use of the wander-guard bracelet and that staff should check the alarm for functioning. The Wander/Elopement Care Plan, dated October 15, 2012, indicated Resident A was at risk for elopement and wandering out of the facility. (Resident A actually eloped that day). The interventions included wearing the wander-guard bracelet, check the alarm for functioning and frequent visual checks. There was no documentation to show the facility included interventions to keep the resident safe from elopement after the resident?s first attempt to leave the facility.According to the Administrator, there were two residents on the wander-guard system during this time period. The Nurse?s Notes, dated October 15, 2012, indicated Resident A was walking in the hallway around midnight and was assisted back to his room. At 2a.m., while making bed rounds, the CNA noted Resident A?s bed was empty. The staff started looking around the facility for Resident A and were not able to find him. The DON was called. At 2:15 a.m., the LAPD was called. At 2:30 a.m., the DON and the Police were communicating to find the resident. At 3:35 a.m., the family member was notified that Resident A was missing from the facility. At 5 a.m., the family member brought a picture of the resident to the facility to aid in the search. At 7:20 a.m., the physician was notified regarding Resident A being missing. At 1:35 p.m., the notes indicated Resident A was found by a college employee on a nearby college campus. On October 29, 2012, during an interview, the DON said Resident A eloped from the side door of the facility where there was no wander guard system. An observation of the room where Resident A resided at the time of his elopement revealed there were sliding glass doors in the room and a patio area outside of the glass doors. There was a door at the end of the patio that opened to an outside sidewalk away from the perimeter of the facility. According to the DON, Resident A eloped through the door at the end of the patio without being detected because the wander-guard system was not installed on that door. There was no documentation to show the facility implemented any other safety measures to keep the resident from eloping. On November 21, 2012 at 9:30 a.m., during an interview, LVN 1 said the night of the incident (she worked the 11-7 shift) RN 1 told her Resident A was missing. LVN 1 helped look for the resident inside the rooms and bathrooms. LVN 1 also walked around the outside of the facility and across the street. By the time her shift was over, the resident still had not been found. On November 21, 2012 at 9:40 a.m., during an interview, CNA 2 stated on the night of the incident, he last saw Resident A at midnight. At approximately 1 a.m., he was told Resident A was missing. He helped look for the resident inside and outside of the facility. CNA 2 said the police came and also helped look for the resident. They did not find the resident by the time CNA 2?s shift was over. CNA 2 said the wander-guard system was working and he thought Resident A had his wander-guard bracelet on. On November 21, 2012 at 12:20 p.m., during an interview, CNA 1 said the night of the incident she was assigned to take care of Resident A. CNA 1 said it was her third day of employment at the facility. CNA 1 received orientation on station 1 but not station 2. CNA 1 said she did not know that Resident A had a history of trying to elope from the facility. CNA 1 said she had 17 residents that night and it was hard to check each one frequently. At 12 a.m., she went to check on Resident A and he was ?okay.? She went back at 1:30 a.m., his door was closed. She opened his door and discovered he was gone. CNA 1 told RN 1 that Resident A was gone. They all looked around the facility for Resident A, were unable to find him and the Police were notified. CNA 1 said at the time of the incident she was 10 rooms away and did not hear any alarms or beeping, so she did not know if Resident A had his wander-guard bracelet on. CNA 1 said she was terminated by the facility because of this incident. During a phone interview on January 14, 2013 at 9:50 a.m., with the college employee who found Resident A wandering inside the lobby of the career center on the college campus where the resident was found, on October 15, 2012, at approximately 12:00 p.m., she stated the resident seemed confused. She was not able to understand everything he was saying because it did not make sense. However, he was able to tell the employee the names of his family members. The employee said the resident spoke another language other than English and she was able to communicate with him in that language. The employee went on to say the resident had shoes on his feet, an extra shoe in his hand and was wearing regular street clothes. The resident told her that the facility staff did not treat him very well and he wanted to go home. The employee noticed the resident had on an identification bracelet. She called the facility and told them she found Resident A on the college campus. The employee said about 40 minutes later, the Police came and picked up the resident.The failure of the facility to provide adequate supervision and monitoring resulted in Resident A attempting to elope from the facility on September 29, 2012. On October 15, 2012, the resident actually left the facility without the knowledge of facility staff. This violation had a direct relationship to the health, safety or security of Resident A. |
| 920000092 |
Stoney Point Healthcare Center |
920009923 |
A |
21-Jan-14 |
A11R11 |
11064 |
T 22 - Section 72311 (a)(1)(A)(B) (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. Based on observation, record review and interview, the facility failed to identify patient care needs to prevent accidents or reduce the incidence of fall which resulted in a sub-acute subdural hematoma (a collection of blood on the surface of the brain as a result of head injury) when Patient 1 fell out of bed by failing to: 1. Ensure that a patient, who was assessed to be a high risk for falls and had a tendency to lean his leg on the side rail was provided with full side rails. 2. Develop a plan of care for the patient?s care needs based on the assessment of health professionals to prevent injury from fall. On January 10, 2012, an informal office conference was conducted in the Licensing and Certification District Office. Family Member (FM2) stated that Patient 1 always laid on his right side with his legs against the side rails.On February 3, 2012, a telephone interview with a family member (FM1) by Evaluator 2 revealed that Patient 1 was moved across the hall in a bed that only had guard rails on the top of the bed. He further stated that the previous bed was set up with full side rails on both sides and had padding on the rails to protect the patient. FM1 stated that the side rails had been discussed previously during a care plan meeting. They discussed that the side rails were necessary because of Patient 1's physical condition that created constant forward movement in his legs.FM1 stated that when he visited Patient 1 on March 5, 2011 between 5pm and 6pm, the patient had slurred speech and was constantly moving. There was a rubber mat on the floor and on top of that was his food tray which was on the overbed table with bars and wheels. He also stated that the overbed table should have never been on the mat because if he fell he would hit his head on the bars. He asked the staff why this new bed did not have the full side rails like the other bed. FM1 stated he had to reposition Patient 1 approximately 4 - 5 times back to the bed because his legs were falling off the bed. He said he told the nurse at the nursing station who agreed that Patient 1 should be on a bed with full side rails. On February 6, 2012 at 3:30 p.m., a re-investigation of a complaint was conducted at the facility by Evaluator 1 as a result of an informal office conference.A low bed was observed in a room that was similar to the bed that Patient 1 used according to the director of nursing (DON). The top of the bed was about 2 feet high and had 2 half side rails located towards the head of the bed. A review of the medical record revealed Patient 1 was admitted to the facility on December 15, 2010, with the diagnoses of multiple joint contracture, abnormal posture, hypertension and cerebrovascular accident (stroke- occurs when the blood supply to part of your brain is interrupted or severely reduced). The Fall Risk Assessment, dated December 15, 2010, indicated Patient 1 had a score of 14 (total score above 10 represents high risk). The Siderail Assessment, signed by the MDS nurse coordinator and dated December 15, 2010, indicated recommendations for bilateral side rails, and "none" on half rails were checked.The care plan, dated December 15, 2010, indicated Patient 1 was a high risk for falling or related injury due to poor safety judgment and history of falls. The goal was to attempt to prevent a fall occurrence. The care plan approaches included to monitor the resident?s whereabouts, provide a safe and hazard free environment, apply yellow bracelet to alert staff of the risk for fall, and to place the bed with one side against the wall.A review of the Siderail Assessment signed by the Interdisciplinary Team on December 15 ? 17, 2010, indicated Patient 1 had history of falls, had poor trunk control, and no possibility of climbing over the siderails. The recommendation was to use bilateral side rails. However, this recommendation was not addressed in the care plan.According to FM1 and FM2, the side rails were always used to prevent the patient from falling out of bed, since his admission. On December 17, 2010, there was a physician's order for Patient 1 to have physical therapy daily five times a week for four weeks. The treatment plan consisted of activity tolerance for sitting and standing, and bed mobility for rolling and supine to sit. The Minimum Data Set (MDS) assessment, dated December 25, 2010, indicated Patient 1 rarely made self-understood, sometimes understood others, had severely impaired cognitive skills for decision making, was physically and verbally abusive towards others, needed extensive assistance with one person physical assist in bed mobility, was totally dependent on staff with the rest of his activities of daily living, had functional limitation in range of motion on both sides of the upper and lower extremities and had no physical restraints.The Physical Therapy (PT) Plan of Treatment, dated January 10, 2011, indicated Patient 1 had 90 degree bilateral hip contractures (unable to straighten hips). Patient 1 had severely impaired safety awareness and required 100% tactile and verbal instruction/cues. He was unable to maintain sitting balance without moderate/maximum support. The Siderail Assessment, dated March 1, 2011, indicated Patient 1 was observed getting out of bed and had poor safety judgment. He was also assessed as requiring extensive assistance with bed mobility and was dependent with transfers. The recommendation was for no side rails. The care plan, dated on the same date, indicated Patient 1 was observed trying to get out of bed and the right leg was found dangling over the side rails. The care plan approach was to place Patient 1 on a low bed with a landing pad. However, the plan could not prevent Patient 1 from falling from a low bed that was approximately two feet high. On March 1, 2011, a Notice of Room Transfer was issued and it was documented that FM1 was notified on the same date. Patient 1 was moved to another room and to a different bed (low) with a landing mat placed on the floor. The Nurses? Weekly Progress Notes dated January 7 thru March 4, 2011, indicated the use of side rails times 2 for safety. However, since Patient 1 was transferred to a low bed on March 1, 2011, the bed was only equipped with side rails towards the top of the bed. The Nurses? Notes, dated March 5, 2011 at 6:50 p.m. indicated Patient 1 had unclear speech with slight drooping on the right side. At 7:00 p.m., the physician was notified and ordered a transfer to the hospital for stroke evaluation. The note indicated the patient was on a low bed with a landing pad to "prevent from fall." At 7:40 p.m., Patient 1 was found on the floor on the landing mat. Patient 1 was assessed by a licensed staff member as having no injuries. The notes also indicated that FM 2 was present while the patient was still on the floor from the fall. At 8:15 p.m., the patient was taken by an ambulance to the acute hospital. A review of the medical record from the GACH indicated Patient 1 sustained a subdural hematoma from a fall, and the neurosurgeon did not recommend any surgical intervention. The GACH Nurse's Notes, dated March 5, 2011 at 11:35 p.m., indicated the resident was laying against the side rails, and was leaning toward the right side. On May 10, 2013 at 9:25 a.m., during a telephone interview with the DON by Evaluator 1, she stated that the resident had a tendency to lean his leg on the side rails. The DON was asked why the recommendation on the Side Rail Assessment dated March 1, 2011, indicated the resident needed no side rail if he had a tendency to lean his legs on the side rails. The DON was not able to answer why they made that recommendation. The DON was also asked where the overbed table was placed after meal times. She stated that it should be on the side of the bed on top of the mat or beside the mat. On January 9, 2014 at 4:00 p.m., during a telephone interview with the DON by Evaluator 1, she stated that the use of side rail is a part of their intervention or approach for safety once the resident is identified as fall risk. However, she did not know why the use of side rails was not added to the approach on the care plan for Patient 1. The DON further stated there was no need for the physician to order the side rails if it is not use as a restraint.The facility failed to identify patient care needs to prevent accidents or reduce the incidence of fall which resulted in a sub-acute subdural hematoma (a collection of blood on the surface of the brain as a result of head injury) when Patient 1 fell out of bed by failing to: 1. Ensure that a patient, who was assessed to be a high risk for falls and had a tendency to lean his leg on the side rail was provided with full side rails. 2. Develop a plan of care for the patient?s care needs based on the assessment of health professionals to prevent injury from fall. The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious had a direct relationship to the health, safety, and security of Patient 1. 4 |
| 970000097 |
SKYLINE HEALTHCARE CENTER-LOS ANGELES |
920010739 |
B |
22-May-14 |
2IOY11 |
6939 |
42 CFR section 483.20(1)(3)F284 - When the facility anticipates discharge a resident must have a discharge summary that includes a post-discharge plan of care that is developed with the participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment. On January 28, 2013, the Department received a complaint regarding the facility discharged Resident 1 against medical advice (AMA) after he returned from being out on pass with a friend. Licensed Vocational Nurse 1 (LVN 1) called the police, who escorted him out of the facility. On January 29, 2013, an unannounced complaint investigation was conducted at the facility. Based on observation, interview and record review the facility failed to: Provide a post-discharge plan of care for a resident who had diagnoses that included: right foot osteomyelitis, right foot dislocation with fracture (minimal weight bearing status on right foot), diabetic neuropathy and diabetes mellitus. Resident 1 was escorted out of the facility by the police after he returned from being out on pass with a friend. His belongings were also put out on the side walk by LVN 1. The resident was not given his medication, food, or water and he had no place to go. The failure of the facility to provide a post-discharge plan of care resulted in the resident feeling displaced, ill, and calling the paramedics, who arrived and transported the resident to a general acute care hospital (GACH) for evaluation and treatment. A review of the medical record revealed physician?s orders dated December 24, 2012, as follows: 1. Accucheck before meals with Novolog sliding scale for diabetes mellitus. 2. Actos 30 milligrams (mg) daily for diabetes mellitus 3. Levemir 10 units daily for diabetes mellitus. 4. Neurontin 300 mg daily for neuropathy. 5. Norvasc 5 mg daily for hypertension. The physician?s order dated January 1, 2013, indicated Resident 1 could go out on a pass for four hours a day. The physician?s order dated January 15, 2013, indicated Resident 1 may be discharged to an Assisted Living Facility (ALF) when arrangements could be made. According to documentation by the Director of Nursing (DON) Resident 1 went out on pass with a family member on January 25, 2013, at 4:30 p.m. At 9 p.m. Licensed Vocational Nurse (LVN) 1 called Resident 1 on his cell phone and left a message on his voicemail. At 11:30 p.m. LVN 1 called Resident 1 again and left another message. At 11:45 p.m. LVN 1 finally reached Resident 1. According to the documentation the nurse explained that the pass was only for four hours.On January 26, 2013, at 8 a.m. according to the documentation the resident had not returned, so the nurse called the resident on his cell phone. Resident 1 did not answer, and the nurse was unable to leave a message. The nurse called Resident 1?s doctor and he gave a verbal order to discharge the resident AMA. At 6:50 p.m. Resident 1 came back to the facility (after 26 hours). He was informed that his doctor discharged him AMA. At 7 p.m. Resident 1 refused to leave the facility, so the nurse called the police, who arrived at 9:20 p.m., and escorted the resident out of the facility with his belongings. Resident 1 then called the paramedics and they arrived at 11 p.m. The paramedics asked the facility staff to keep the resident?s belongings as a courtesy. The paramedics took the resident to an acute care hospital for evaluation and treatment, where he was admitted.On January 28, 2013, at 2:05 p.m. during a phone interview with Resident 1, he said he was at a bus stop in Inglewood waiting for a friend to pick him up. The resident said he was escorted out of the facility by the police after coming back from being out on pass, and didn?t have any place to go. He said one of the nurses also put his belongings on the side walk, and he was not given his medication after being escorted out of the facility. The GACH admitted him overnight and discharged him the next day. He said he had a cast on his right foot, could hardly walk, and only had 20 dollars when he was put out of the facility. He had to eat and only had two dollars left and no food, water or medication.At 2:16 p.m. on January 28, 2013, during a telephone interview, Administrator 1 was informed that Resident 1 called our office and said he was sitting at a bus stop in the city of Inglewood waiting for a friend to pick him up, who may or may not show up. Administrator 1 said Resident 1 decided he did not want to come back when he went out of the facility on pass. Administrator 1 was informed that Resident 1 tells a different story, stating that he was escorted out of the facility by the police and his belongings were put on the side walk.During a telephone interview with the director of operations for the facility at 3:10 p.m., she said when the resident did not return to the facility when he was supposed to, the nurses called his physician, who gave an order to discharge the resident AMA. When the resident returned to the facility after about 26 hours the physician would not write an order to readmit him. During an interview on January 29, 2013, at 3:50 p.m., Administrator 2 said Resident 1 was still in the acute care hospital, and was not sure when Resident 1 was going to be readmitted to the facility. On January 29, 2013, at 4:30 p.m., during an interview the social service designee (SSD) said Resident 1 was looking for another place to live. The SSD was unable to provide documented evidence that the facility had done any pre- or post-discharge planning for Resident 1, including discharge to an ALF.During an interview on January 30, 2013, at 8:15 a.m. Resident 1 said he was going to be discharged from the GACH that afternoon and readmitted to the facility. On January 31, 2013, at 4 p.m. the evaluator arrived at the facility and met with the resident to verify he had been readmitted.During an interview on January 31, 2013, at 4:30 p.m., LVN 1 said when Resident 1 returned from being out on pass for 24 hours she called the administrator. Administrator 1 told LVN 1 the doctor discharged the resident AMA so call the police on him. The evaluator asked LVN 1 if the resident was being disruptive or doing anything illegal, she said, ?No?. LVN 1 could not provide documentation that the resident had discharge planning or that he was given his medication when he was put out on the side walk. She said she had the police escort the resident out of the facility and put his belongings on the side walk because Administrator 1 told her to.The failure of the facility to provide a post-discharge plan of care resulted in the resident being displaced, feeling ill and calling the paramedics, who arrived and transported the resident to a GACH for evaluation and treatment. This violation had a direct relationship to the health, safety or security of Resident 1. |
| 920000008 |
SHERMAN VILLAGE HEALTHCARE CENTER |
920011186 |
B |
17-Dec-14 |
OVZY11 |
6437 |
F224 483.13 (c) Prohibit Mistreatment/Neglect/Misappropriation of Property The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.The facility failed to prevent financial abuse by failure to implement its policy for the Employee Handbook related to financial abuse. Employee 1 used Resident 1's EBT (Electronic Benefit Transfer Card/Food Stamp) Card for her personal use, to accept tips, and obtained the code for the EBT Card and account. Employee 1 used the EBT Card for purposes not intended or approved by Resident 1. A Recertification survey was conducted from November 3, 2014, through November 6, 2014. On November 4, 2014, at 11 a.m., during an interview, Resident 1 stated she had asked Employee 1 to purchase some personal items from the "99 Cents Only Store." She gave Employee 1 a list of the items, $10 in cash and her EBT Card to purchase the items. According to Resident 1, the itemized list included the following:1. A calculator 2. One Colgate toothbrush 3. Four bags of butterscotch candies $1 each bag 4. Cotton balls 5. Nail Polish remover 6. Vo5 Volume Conditioner 7. Q-Tips 8. A White OutResident 1 stated she gave Employee 1 the code to her EBT Card to purchase the items. She said Employee 1 did not follow her request to purchase the items from the "99 Cents Only Store." Instead Employee 1 purchased the items from a liqueur store, and did not give the resident the receipt to the merchandise. Resident 1 stated that Employee 1 returned $3 which was the unused portion of the $10 cash. Resident 1 stated she then gave Employee 1 a $1 tip for running the errand for her. Resident 1 stated she was unhappy because she did not receive all the items she requested Employee 1 to purchase for her. She said that instead of buying the Colgate tooth brush, Employee 1 bought Colgate tooth paste, so she returned the tooth paste to Employee 1.During the same interview on November 4, 2014, Resident 1 stated Employee 1 asked her if she could borrow the EBT Card for $5. Resident 1 stated on November 5, 2014, she became suspicious about Employee 1's action and she called the EBT Card Center and requested a copy of the transaction on her EBT account. When she reviewed the computerized print out she received from the EBT Card Center, she discovered that her EBT Card was not used in the "99 Cents Only Store."Instead, Employee 1 had used the EBT Card to purchase food items without Resident 1's authorization in the amount $35.18 on November 1 and 2, 2014. During an interview with the administrator on November 4, 2014, at about 5 p.m., he stated he was unaware of the financial incident with Resident 1, and would investigate immediately. On November 5, 2014, at 11:30 a.m., after he had begun his investigation and interviewed Resident 1, he stated Resident 1 informed him that on November 3, 2014, she gave Employee 1 $10 cash and her EBT Card with her code to purchase some items. She said that Employee 1 used her EBT Card to make three purchases totaling $51.70 without her permission.Employee 1 was not available for an interview to validate Resident 1's allegation. According to the administrator, Employee 1 was suspended pending investigation by the facility. The admission record indicated Resident 1 was admitted to the facility on April 23, 2014, with diagnoses that included depressive disorder. The Minimum Data Set [MDS- standardized assessment and care screening tool] dated October 27, 2014, indicated that Resident 1's cognition was intact, and she required supervision from staff with her care needs. Resident 1 had no functional limitation in range of motion, and walks by herself using a walker. During an interview with a Licensed Vocational Nurse (LVN 2) on November 5, 2014, at 12:30 p.m., she said she called Employee 1 on the phone and asked if she had run an errand for Resident 1 on November 3, 2014. Employee 1 answered "Yes" that she was doing Resident 1 a favor to purchase some items at the "99 Cents Only Store" for the resident. According to LVN 2, Employee 1 admitted receiving $10 cash and an EBT Card with the code from the resident for the purchases. LVN 2 stated Employee 1 told her she had permission to use Resident 1's EBT Card but denied using the card to purchase food items for herself. LVN 2 stated Employee 1 had told her she was willing to refund any amount the resident claimed the balance she owed for use from her EBT Card. When asked if the facility had a policy regarding accepting money from residents, LVN 2 replied "I don't know."On November 6, 2014, at 1: 25 p.m., during an interview with the Activity Director (AD), she stated Resident 1 was always asking staff to do favors by running errands for her, and she would express that she was losing her stuff in the facility such as her blouses, which were replaced by facility. The AD stated she had accompanied Resident 1 for shopping. After a few days, the resident would change her mind and ask her to return those items back to the store. She stated the resident would ask several staff members to use her EBT Card to buy things for her, and staff were told to direct her requests to the Social Service Department. The AD said she had warned Employee 1 to be careful running errands for the resident because Resident 1 would accuse her for using her card and also would ask her to return the purchased items to the store. The AD stated on several occasions, Resident 1 had offered her the same EBT Card to use and purchase foods for her children, but she declined the offer. A review of the Employee Handbook dated August 2010, Page 18, Section 32, signed by Employee 1 as receiving it, indicated an employee may be discharged for borrowing, soliciting or accepting gifts of any type, tips, monetary or donations from residents, visitors, vendors or others. Therefore, the facility failed to prevent financial abuse by failure to implement its policy for the Employee Handbook related to financial abuse. Employee 1 used Resident 1's EBT Card for her personal use, to accept tips, and obtained the code for the EBT Card and account. Employee 1 used the EBT Card for purposes not intended for or approved by Resident 1. The above violation had a direct relationship to the health, safety and security of Resident 1. |
| 920000289 |
SYLMAR HEALTH AND REHABILITATION CENTER |
920011839 |
AA |
15-Jul-16 |
None |
12514 |
F309 42 CFR 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. F323 42 CFR 483.25(h) Accidents The facility must ensure that ? (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The facility staff failed to ensure the resident environment remained as free of accident hazards as possible. The facility staff failed to ensure Resident 1, who had a history of suicide attempt, was provided adequate supervision and services to prevent him from committing suicide, including failures to: 1. Revise his care plan after a first suicide attempt, to include specific interventions to ensure his safety as indicated in the facility?s ?Suicide Threat Policy;? and 2. Ensure his environment was free of dangerous items according to the facility?s policies and procedures. As a result, on February 23, 2013, Resident 1 hanged himself in his room. The Department received an entity reported incident (ERI) on February 25, 2013, indicating Resident 1 had committed suicide by placing a rope around his neck and hanging himself on February 23, 2013. During an unannounced visit on February 25, 2013, Resident 1?s admission record indicated he was a 40 year old male, admitted to the facility on January 15, 2013. The resident?s diagnosis included schizophrenia paranoid type (mental disorder often characterized by abnormal social behavior and failure to recognize what is real), antisocial personality disorder (pattern of disregard for others' rights), and drug abuse. A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated January 21, 2013, indicated Resident 1 had a potential for hallucinations and delusions (seeing and hearing things that were not real). He had difficulty focusing and was disorganized in his thinking. Resident 1 had a care plan dated January 15, 2013, as follows: a. Potential for negative symptoms such as depression, isolation, anxiety, agitation, mood swings, related to new living situation. The interventions included staff to encourage resident to discuss feelings, medications as ordered and notify the physician if ineffective, encourage group attendance; and b. At risk for isolation related to antisocial personality. The goal was to not isolate himself. The interventions included participate in activities, listen attentively and attempt to resolve issues when appropriate, and encourage talking about feelings. The facility had a generic blank "Plan of Care: Short Term", for the problem of voicing suicidal thoughts, had a goal to not harm self within the next 3 months. Interventions included to monitor the environment for possible hazards. This care plan was not completed for Resident 1, to be used for any resident having suicidal thoughts. A review of the Psychosocial Assessment dated January 21, 2013, under general history indicated Resident 1 had a family history of mental illness and suicide. The notes indicated Resident 1 stated he didn?t want to be ?here.? The Nurses Notes dated February 17, 2013, at 5 p.m., indicated Resident 1 had attempted to kill himself in his room by putting the curtains around his neck. The documentation indicated there was slight redness observed around his neck, but no bruises or injury noted. Resident 1 was placed on 1:1 supervision (direct observation by one staff person at all times), due to suicidal ideations (thoughts to kill himself), for 72 hours. Staff were to monitor for 1:1 effectiveness. The Physician's Orders dated February 17, 2013, at 5 p.m., indicated Resident 1 was placed on 1:1 supervision for suicidal ideations for 72 hours, noted and carried out. On February 18, 2013, at 10:00 a.m., the Licensed Nurses Notes indicated staff and the sitter reported that Resident 1 was verbally threatening to hit them. Verbal redirection was given three times, but was ineffective. Ativan (used to treat anxiety disorders or anxiety associated with depression) PO (by mouth) was given and was effective after 30 minutes. Resident 1 stated he was all right. A routine physician Assessment and Recommendation notes form dated February 18, 2013, (no time) indicated Resident 1 "was suicidal" and complained of shuffling gait. The recommendation was to observe Resident 1 for deterioration of mood, suicidal ideation or increased agitation. The Physician's Orders dated February 18, 2013, at 11 a.m., 24 hours after the order for 72-hour 1:1 supervision, indicated to discontinue 1:1 supervision, and place resident on every 15 minute checks related to status-post suicidal ideations (thoughts) for 72 hours, noted and carried out. The IDT (interdisciplinary team) notes dated February 18, 2013, (no time) indicated the psychiatrist met with Resident 1, who stated, ?I play with curtains.? He ?contracted? not to harm himself. The recommendation was to discontinue the 1:1 supervision, and place the resident to observation every 15 minutes. The Nurses Notes dated February 18, 2013, at 11 a.m., referred to the IDT?s recommendation because Resident 1 ?contracted to safety.? The physician ordered at 11 a.m. to discontinue the 1:1 supervision, and ordered observation by staff every 15 minutes, related to suicidal ideation (thoughts), for 72 hours. On February 18, 2013, at 11:40 a.m., the Nurses Notes indicated Resident 1 was seen by a physician and the physician was informed of Resident 1's attempted suicide. Resident 1 complained of shuffling gait and of being depressed. Medications were changed and Prozac (medication to treat depression) was ordered. On February 20, 2013, at 4:40 p.m., the Nurses Notes indicated Resident 1 was evaluated by the physician. On February 21, 2013, at 11 a.m., the notes indicated Resident 1 completed the every (Q) 15 minute supervision. There were no Nurses Notes documented after this until Resident 1?s suicide on February 23, 2013 at 6:20 a.m. During an interview with the Director of Nursing on February 25, 2013, while reviewing Resident 1's medical record, he stated there was no documented nursing notes after February 21, 2013, until Resident 1's suicide. He stated there was no plan of care for suicide prevention. The Monthly Progress Notes dated February 22, 2013, indicated Resident 1 had frequent hallucinations, and was observed attending to internal stimuli on a daily basis, and pacing the courtyard and the facility halls throughout the day. A review of the February 2013 medication record (MAR) for monitoring Resident 1 for thought disorder, indicated staff had documented Resident 1 had ?negative behavior? on February 17, 18, 20, 21, and February 23, 2013, on the 11 p.m. to 7 a.m. shift. There was no documentation in the medical record to explain the nature of Resident 1?s ?negative behavior?. The February 2013 MAR on the 7 a.m. to 3 p.m. shift, indicated Resident 1 had ?negative behavior? on February 21 and February 22, 2013; and on the 3 p.m. to 11 p.m. shift on February 21 and February 22, 2013. There was no documentation in the medical record to explain the nature of Resident 1?s ?negative behavior?. A review of the ?1 to 1 Supervision? Reason for Close Supervision, Required Duties form dated February 17, 2013, indicated at the beginning of each shift, staff are to search the resident, the resident?s belongings and room for dangerous items, such as sharp items, keys, belts, "etc". A review of the completed "1:1 Supervision" forms indicated staff started 1:1 monitoring on February 17, 2013, at 5 p.m., and completed the 1:1 on February 18, 2013, at 11 a.m. (18 hours). The "Q 15 Minutes Check Form" indicated the staff performed the duties (by initials) starting February 18, 2013, at 11 a.m., and completed February 21, 2013, at 11 a.m. The facility?s undated ?Report of Investigation? indicated at 6:20 a.m., the resident?s roommate (B) came out of their room and told the CNAs that his roommate was ?hanging?. The CNAs ran to the room and found Resident 1 with a string around his neck, hanging. Staff responded and found the resident?s heels touching the floor prior to any action. The resident was assisted to the floor and CPR (cardiopulmonary resuscitation - life saving measures) was immediately performed and continued until the paramedics arrived and took over. The Maintenance Supervisor found the remaining "string" wrapped around six or seven privacy curtain hangers multiple times. A review of the Nurses Notes dated February 23, 2013 at 6:20 a.m. indicated Resident 1 hanged himself with a string that looked like a shoe lace. The resident was taken down and CPR was initiated. The paramedics arrived and pronounced the resident dead at approximately 6:50 a.m. During interviews with Resident 1?s roommates on February 25, 2013, between 10:50 a.m. and 11 a.m., Roommate B stated he didn?t remember the time of the incident, but saw Resident 1 hanging from a curtain. He said he was scared, and pointed to the curtain stating Resident 1 stepped on the bed and hanged himself. Resident C stated he heard Resident B screaming and saw Resident 1 hanging from what he thought was a string. He stated the ambulance crew came and said Resident 1 was dead. In an interview with the certified nursing assistant (CNA 1) on March 1, 2013, at 8:10 a.m., she stated she saw Resident 1 hanging from a ?shoe lace? from the curtains. The string was wrapped around plastic, and hanging from on top of the curtain, dangling. She and CNA 2 were yelling for help. She ?burned? the rope with a ?lighter? to cut it, while CNA 2 held Resident 1 up. Then they lowered the resident to the floor. Other staff came and started CPR. CNA 1 cut the rest of the rope, which was tight around Resident 1?s neck. A review of Resident 1?s care plans on March 1, 2013, with Licensed Vocational Nurse (LVN) 1, revealed no revision to include Resident 1?s previous attempt to put the curtains around his neck on February 17, 2013. There were no specific interventions to prevent suicide. An affidavit dated March 1, 2013, written and signed by LVN 1, indicated during a review of Resident 1?s chart, a suicide intervention care plan was not completed for Resident 1. LVN 1 documented the facility did not provide staff training/in-services for prevention and 1:1 supervision, suicide, or accidents. On March 1, 2013, during an interview, an affidavit was received from Employee 2 who indicated she had not given an in-service on suicide prevention in the past year. A review of the undated "Suicide Threats" Policy indicated the policy is to ensure the safety of all residents in the cases of suicidal attempts. An assessment of the resident?s behavior will be made of such incidents to determine intervention that may be necessary to prevent recurrence. Licensed nursing staff will evaluate the need for PRN (as needed) medications. Revised care plans will be developed to reflect such intervention. Nursing and/or Rehabilitation staff will perform locker and body search for objects which may be used to harm self (i.e., sharp objects, pens/pencils, strings head phones, etc.). Suicidal clients are not allowed to use these articles unless nursing staff feels it is safe to do so with constant and ample supervision. The facility staff failed to ensure the resident environment remained as free of accident hazards as possible. The facility staff failed to ensure Resident 1, who had a history of suicide attempt, was provided adequate supervision and services to prevent him from committing suicide, including failures to: 1. Revise his care plan after a first suicide attempt, to include specific interventions to ensure his safety as indicated in the facility?s ?Suicide Threat Policy;? and 2. Ensure his environment was free of dangerous items according to the facility?s policies and procedures. As a result, on February 23, 2013, Resident 1 hanged himself in his room. The above violations presented imminent danger of death or serious harm, or a substantial probability of death or serious physical harm, and was a direct proximate cause of Resident 1?s death. |
| 920000289 |
SYLMAR HEALTH AND REHABILITATION CENTER |
920012214 |
B |
04-May-16 |
UDDK11 |
7848 |
Based on interview and record review, the facility staff failed to implement the abuse policy and procedure, known as Pro Act training, and not restrain a resident by themselves, for 1 of 1 sampled residents (1). This deficient practice caused Resident 1 to sustain a skin tear, on his upper lip, after an altercation with Employee A.During an unannounced visit on March 6, 2014, at 2 p.m., an entity reported incident investigation was conducted regarding an allegation of staff to resident abuse. A review of the admission record indicated Resident 1, a 32 year old male, was admitted to the facility on March 14, 2011. The diagnoses included schizoaffective (a mental disorder characterized by abnormal thought processes and deregulated emotions) disorder, polysubstance dependence (disorder in which an individual uses at least three different classes of substances indiscriminately), antisocial personality(a disregard for, or violation of, the rights of others), asthma (reactive airway disease) and anemia [a decrease in the amount of red blood cells (RBCs) or the amount of hemoglobin in the blood]. The Minimum Data Assessment (MDS - an assessment tool) dated December 15, 2013, indicated the resident was cognitively intact, was independent in activities of daily living, and has hallucination (perceptual experiences in the absence of real external sensory stimuli) and delusion (misconceptions or beliefs that are firmly held, contrary to reality). A review of Resident 1's care plan indicated a concern with thought disorder manifested by auditory hallucinations dated December 20, 2013. The interventions indicated the staff was to assist the resident in focusing on real events or activities, reinforce reality, and deferred him from the hallucinations. There was care plan for social inappropriate behavior manifested in horseplay with peers dated December 20, 2013. The interventions included counselors will identify reasons for socially inappropriate behaviors (i.e. - sexual in nature, resident gaining pleasure from staff's reaction, psychosis, etc.), in group and when appropriate counselors will elicit feedback in illustrating how socially inappropriate behaviors affect others, and counselors will outline negative consequences of these socially inappropriate behaviors. There was no intervention on how the facility will prevent escalation of this behavior.On February 20, 2014, there was a care plan written for an allegation that a Certified Nursing Assistant (CNA) 1 engaged in horseplay with Resident 1 and retaliated by kicking the CNA. The interventions included staff will attempt to identify reasons/antecedents for the false allegation (i.e. need related psychosis, coping mechanisms, general belief on addressing any problems, etc.), counselors will elicit peer feedback to illustrate how false allegations affect others. A review of the Licensed Nurses Notes dated February 20, 2014 at 9:30 a.m., and a Report of Investigation dated February 20, 2014, written by Employee B indicated on February 20, 2014, he heard "Code green" (indicating an emergency situation) in Resident 1's room, announced over the intercom. When Employee B arrived to the room, Resident 1 was sitting on his bed. Employee B asked Resident 1, "What happened?" Resident 1 stated that Employee A stood at the foot of his bed shaking it, and him, to get him up for his medication. Words were exchanged between Resident 1 and Employee A and the resident kicked Employee A's hand off the foot of his bed, as a joke. Employee A came toward the resident. Resident 1 stood up and that is when Employee A started to punch him in his abdomen area and pulled the resident's shirt over his head. According to the Licensed Nurses Notes, Resident 1 had small skin tear on his upper lip measuring approximately one centimeter. The Report of Investigation indicated the resident was unsure how he obtained the skin tear on his lip, but stated it possibly happened during the time when the CNA pulled the shirt over his head.The Licensed Nurses Notes also indicated Employee B interviewed Employee A prior Employee A leaving the facility on February 20, 2014. Employee A stated, "The patient kicked me while I was waking him up for medication, and then proceeded to punch me in my chest, and that's when I held him down on his bed until staff arrived". A written statement from Employee B dated February 20, 2014, indicated when he went to Resident 1's room after hearing about the fight, he witnessed Employee A trying to hold Resident 1 down on the bed, by holding down his hands. Employee A stated that Resident 1 kicked his hand while he was tapping on the lower part of the bed to wake him up to take medication. To Employee A, this was the beginning of an attack, which he wanted to prevent by pushing and holding down the resident. To Resident 1, Employee A attacked him for no reason, because he was just joking when he kicked Employee A's hand. During an interview, with Resident 1 on March 6, 2014, at 3:30 p.m., he stated the day of the incident was lying in bed and Employee A started shaking the foot of his bed. Resident 1 told Employee A to stop shaking his bed, then kicked Employee A's hand off his bed. Resident 1 stated they were only playing around, because that is how they get along. Employee A took it seriously, and hit Resident 1 in the mouth and nose with the palm of his hand. He also hit him in his stomach. Resident 1 stated his nose and lips started to bleed and swell. Resident 1 stated he told Employee A, that he was not supposed to hit him, only take him down to the ground. Employee A cursed at Resident 1 saying, "You hit me". According to Resident 1, another resident saw what was going on, and shouted, "They are fighting". Other staff members came running to Resident 1's room. The staff saw him (Resident 1) bloody and took him to the activities of daily living (ADL) room to wash his face and gargle with salt water. Resident 1 stated that was the first time he has had trouble with Employee A, they usually get along. During an interview with Employee B on March 13, 2014, at 3:30 p.m., he stated on February 20, 1014, he had not witness the actual event. Employee B stated he went running to Resident 1's room after he heard, "Code green" over the intercom. Employee B stated he did not see the cut on Resident 1's lip. Yet the Licensed Nurses Notes, written by Employee B, indicated Resident 1 had a skin tear on his upper lip.Employee A was not available for interview. Review of Employee A's personnel file indicated he was hired on October 16, 2009. The employee received Professional Assault Crisis Restraint certificated on August 29, 2012 and signed as reading the facility's Abuse and Neglect Prohibition on October 19, 2009.On March 6, 2014, during an interview, the Director of Nurses (DON) stated Employee A was terminated on February 25, 2014, because he did not follow the facility's policy and procedure regarding the "Buddy System", which means that the employees are never go into the resident's room alone. The DON stated all staff, including Employee A, had an in-service in December 2013 regarding the "Buddy System".A review of the facility's policy on "Abuse Prevention Program-Pro Act Training" indicated staff will not restrain residents by themselves: 1. If faced with a situation where a resident is aggressive or combative and staff is alone, they are to use Pro Act (an industry accepted and valuable tool in training health care staff in managing crisis situations) evasion techniques and call out for staff assistance; 2. They are to leave the room if at all possible.The above violation jointly, separately,or in any combination had a direct or immediate relationship to Resident 1's health, safety, or security. |
| 920000075 |
STUDIO CITY REHABILITATION CENTER |
920012307 |
AA |
8-Feb-17 |
IVLG11 |
26334 |
F309
CFR 483.25
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
The facility failed to assess, monitor, and react promptly to Resident 1's change in bowel movement (stools) habits, to prevent constipation before it progressed to fecal impaction [a solid, immobile bulk of stool that can develop in the rectum or colon (large intestine) as a result of chronic constipation and prolonged retention of stool. While this stool may be too large to pass, loose, watery stools may be able to get by, leading to diarrhea or leakage of fecal material], by failing to, including but not limited to:
1. Utilize Resident 1?s past diagnoses and treatment of rectal bleeding, constipation, colon surgery, when conducting the initial assessment and plan of care.
2. Assess Resident 1's bowel habits, including monitoring the characteristics of the stools for frequency, color, amount, and consistency (soft, formed, hard, watery) of the stools, as indicated in the plan of care.
3. Implement Resident 1?s care plan interventions to prevent constipation, including inadequate fluid intake, immobility, and pain medications that could lead to suppression of defecation (bowel movements), constipation, and fecal impaction.
4. Consistently assess and monitor for side effects of consistent use of narcotic pain medications that included constipation.
5. Consistently monitor Resident 1?s intake and output (I&O) of fluids to ensure adequate hydration and prevent constipation.
As a result, Resident 1 was admitted to the general acute care hospital (GACH) on XXXXXXX 2009, in severe pain with acute peritonitis (new onset of an inflammation of the tissue that lines the inner wall of the abdomen), from a severe bowel impaction. She was at the emergency room (ER) with an altered level of consciousness, moaning in pain, and had a distended (larger than normal) abdomen. Resident 1 required endotracheal intubation (tube inserted down the throat to provide artificial breathing) at the ER. Her survival rate was deemed to be zero. Resident 1 was diagnosed with a perforated viscus (an abnormal opening in a hollow internal organ in the abdomen), and sepsis (serious blood infection). Resident 1 died in the hospital on XXXXXXX, 2009, two days after her emergency room admission.
The Certificate of Death dated November 16, 2009, indicated the immediate cause of death as (A) Acute Peritonitis for a time period of days; (B) Colon Obstruction And Perforation, with a time period of days; and (C) Severe Fecal Impaction, with an unknown time period. (Fecal impaction of the bowel can cause a perforation of the bowel, sepsis, and if not remedied death).
The autopsy report?s opinion, dated November 12, 2009, stated ?Autopsy confirms the clinical diagnosis of perforated viscus. In this case, there was severe fecal impaction in the sigmoid colon, with perforation.? The autopsy report stated ?Immediate cause? (A) acute peritonitis, Due to, or as a consequence of, (B) colon obstruction and perforation, Due to, or as a consequence of (C) severe fecal impaction.?
On February 16, 2011, the Department received a complaint alleging staff failed to monitor Resident 1?s bowel habits and recognize Resident 1?s change in condition, including notification of the family and the physician for prompt medical intervention when there was a change in condition. The complaint indicated Resident 1 was diagnosed with a perforated (abnormal opening) viscus (internal organ) and sepsis (life-threatening condition that arises when the body's response to infection injures its own tissues and organs), and when Resident 1 had been admitted to the facility, staff had been informed of the resident?s history of a previous perforated viscus.
On March 3, 2011, at 2:45 p.m., an unannounced complaint investigation was conducted at the skilled nursing facility.
A review of Resident 1?s GACH (G-E) History and Physical dated May 31, 2009, indicated the present chief complaint was acute psychosis (new onset of mental disease involving loss of contact with reality), rectal bleeding, hypotension (low blood pressure); she also had a new onset of atrial fibrillation (irregular heart beat). Resident 1 was initially admitted at Mental Health with constipation, and was given laxatives. The resident had some diarrhea and profuse (large amount) bowel movement. Past medical history indicated Resident 1 had previous bilateral (both) hip replacement (no dates indicated). She had acquired methicillin resistant staphylococcus aureus (MRSA - bacteria that does not respond well to certain antibiotic medications) infection after having hip surgery. Her past history diagnoses included hypertension (high blood pressure), degenerative joint disease (breakdown of joints and underlying bone), anemia (low red blood cell count), dementia (decline in mental status), and tachycardia (fast heart beat).
A review of the G-E Pathology Report dated June 5, 2009, indicated a colonoscopy (scope view) of the large intestine that was diagnosed with necrotic debris (dead tissue) consistent with ischemic colitis (inflammatory condition of the large intestine or colon that develops when there isn?t enough blood flow to the area).
A review of Resident 1?s medical record indicated an original admission date to the skilled nursing facility (SNF) from the G-E on June 17, 2009. The SNF Physician's Orders dated June 17, 2009, indicated Haldol one half milligram (mg) (0.5) one tablet by mouth (PO) four times a day (QID) for psychosis manifested by striking out at staff. Monitor behavior every shift and tally by hashmarks. Another order indicated Haldol one mg PO every four hours as necessary (PRN) for adjunct (additional) treatment.
A review of Resident 1?s Dehydration Risk Assessment dated June 17, 2009, indicated she was at risk for constipation.
Resident 1?s Plan of Care for altered behavior pattern related to psychosis manifested by striking out at staff and others dated June 17, 2009, indicated a goal to lessen episodes of striking out at staff and others to once every week or less. Evaluate every three months. The interventions included to administer Haldol as ordered, observe and report signs of adverse effects that included constipation, loss of appetite, and urinary retention.
Resident 1 was discharged to a GACH (G-P) on XXXXXXX 2009, due to a long history of a poor-healing infection of the right hip incision site, severe hip pain, and cellulitis (potentially serious bacterial skin infection). She was diagnosed with a femoral neck fracture (the narrow top end of the large leg bone that connects at the body). She had a right hip replacement and was readmitted back to the SNF on XXXXXXX 2009.
Resident 1?s Minimum Data Set (MDS) assessment (a screening assessment and care tool), dated July 7, 2009, indicated Resident 1 required extensive assistance (2 or more persons) physical assist for bed mobility and transfers. She required one person physical assist for walking, dressing, eating, personal hygiene and bathing. She had an unsteady gait (walk). Resident 1 was occasionally incontinent with bowel continence, and continent with bladder. Her bowel elimination pattern was regular, indicating at least one movement every three days, according to the assessment. The MDS indicated Resident 1 had a wound infection (hip), and she had moderate pain less than daily, from the hip and the incision.
The assessment RAP Summary Focus Review (RAP) dated July 5, 2009, for nutritional status indicated causal and risk factors was therapeutic diet, risk for urinary tract infection (UTI) and dehydration; proceed to care plan. The RAP dated July 8, 2009, for incontinence, indicated Resident 1 had a risk for urinary tract infection, and proceed to care planning. The ?Referrals/Follow-up was to increase fluids as tolerated. There was no RAP for the potential for constipation indicated.
Resident 1?s Care Plan initiated on July 13, 2009, indicated a potential for constipation related to reduced mobility, use of narcotic pain medications, and incontinent of bowel. The short-term goals indicated Resident 1 will be free from signs and symptoms of constipation as evidenced by no abdominal pain, no abdominal distention, no nausea/vomiting, regular bowel movements without complications daily for 90 days; and the resident will be adequately emptied without complications as evidenced by regular bowel movements and no abdominal distention, daily for 90 days. The approaches included evaluate for bowel sounds and abdominal distention, monitor elimination patterns, increase physical activity and fluid intake to promote optimal bowel function, maintain adequate nutrition and hydration, encourage optimal activity to stimulate resident's bowel elimination, and medications as ordered.
Resident 1?s Care Plan initiated on July 13, 2009, indicated alteration in nutrition secondary to mechanically altered therapeutic diet [soft no added salt (NAS) diet]. The approaches included to provide diet/nutrition support as ordered and dietary consultation as indicated. There was no documented evidence the Registered Dietician (RD) had included dietary interventions to include fruits and vegetables, or other foods with natural laxatives and rich in fiber to better manage Resident 1?s constipation, as indicated in the care plan, and the facility?s policies and procedures for constipation.
Resident 1?s Care Plan initiated on July 13, 2009, indicated a potential for fluid volume deficit related to the use of hypertension (high blood pressure) medications and periods of decreased oral intake. The plan indicated the resident had the potential for fluid volume deficit (too little) related to anticoagulant therapy (prevents the thickening of blood). The goal was for the resident to be adequately hydrated as evidenced by moist oral mucosa (mouth tissue), good skin turgor (suppleness), no change in level of care, vital signs (blood pressure, heart rate, breathing, temperature) within normal limits daily for 90 days. The approaches included to monitor hydration status, provide feedings as ordered, monitor intake and record as indicated, monitor urinary output and record as ordered and indicated.
A review of Resident 1?s medical record revealed she was discharged to the G-P on XXXXXXX, 2009, due to her right hip (fracture) surgical site had drainage and was opening. She was treated and readmitted to the SNF on XXXXXXX 2009, with diagnoses added of status post wound debridement.
The Physician's Orders dated September 29, 2009, included:
1. Ferrous sulfate (iron) 325 mg PO three times a day (TID) for anemia (low red blood cell count). [Side effects include constipation and dark tarry stools]
2. Ativan 0.5 mg PO twice a day (BID) for anxiety. [Side effects include constipation]
3. Morphine sulfate (narcotic pain medication) 4 mg intramuscularly (IM-injection) every four hours as needed (PRN) for ?severe? pain. [Side effects include constipation]
4. Norco (narcotic brand name combination medication used to treat moderate to severe pain) 10/325 mg one tablet PO every four hours PRN for ?moderate? pain. (Resident information indicated to take with food or milk, instruct resident to eat high-fiber diet, maintain adequate fluid intake, and use stool softener or bulk laxative to prevent constipation). [Side effects include constipation]
5. Milk of magnesia (MOM) 30 cubic centimeters (cc) PO daily PRN for constipation (laxative).
6. Colace 100 mg PO daily for stool softener.
7. Protonix 40 mg PO daily before (ac) breakfast for GERD (gastroesophageal reflux disease ? stomach contents back up into food pipe).
8. Mechanical soft (easy to chew and swallow, generally chopped, soft foods) no added salt diet.
The Minimum Data Set (MDS) significant change in status assessment initiated September 29, 2009, completed October 12, 2009, indicated Resident 1 was moderately impaired for cognitive skills for daily decision-making, mood persistence had indicators present that were easily altered, and no behavioral symptoms. Resident 1 now required extensive (2 or more persons) physical assist and was totally dependent on full staff performance for bed mobility and transfers; she was totally dependent on full staff performance (with one person physical assist) for locomotion on and off the unit and toilet use; and was not able to walk (not performed); she had no functional limitation in range of motion. The MDS indicated Resident 1 was incontinent of both bowel and bladder and used pads/briefs. Pain symptoms indicated a frequency of pain less than daily, and an intensity of moderate pain. The pain site indicated hip pain and incisional pain. Under section K for oral/nutritional status, the resident's height was 60 inches
and 118 pounds. Nutritional problems indicated the resident leaves 25 percent (%) or more of food uneaten at most meals. Nutritional approaches were mechanically altered therapeutic diet.
Resident 1?s Plan of Care dated September 29, 2009, indicated altered bowel pattern - risk for constipation due to use of narcotic pain management. The goal was to have ?soft formed stools? at ?least? three times a week. The interventions included encourage maximum food/fluid intake to tolerance, encourage and assist out of bed (OOB) as tolerated, monitor bowel movements (BM) daily and record, Colace as ordered, MOM as ordered, and report if ineffective.
Resident 1?s Plan of Care dated September 29, 2009, indicated altered comfort due to generalized pain. The interventions included to administer Norco as ordered for moderate pain; and administer morphine sulfate (MSO4) as ordered for severe pain, and report if ineffective.
The Nutritional Assessment dated September 30, 2009, indicated Resident 1 was on a regular portion, mechanical soft, no added salt therapeutic diet. She required 1609 cc of free water (fluids) per day. The diet provided greater than 2000 cc of fluids per day (if completely consumed). The summary of level of care indicated the resident was at a high risk of excessive weight loss (laboratory data/diagnosis was consistent with potential or presence of malnutrition, or food intake was poor).
There was no documentation on the Nutritional Assessment to indicate the Registered Dietician had considered nutritional/dietary approaches for the medication side effects of constipation; or that the Director of Dietary Services assessed for possible non-pharmaceutical interventions for constipation, in accordance with the facility?s policies and procedures for ?Constipation? and as indicated in the resident?s care plan.
Resident 1?s Pain Risk Assessment dated September 30, 2009, had a total score of 20, indicating she was a "very high? risk for pain. The Pain Assessment dated September 30, 2009, indicated Resident 1 had ?frequent? pain to the right hip/leg. The resident was unable to describe the pain, therefore staff were to assess for moaning, groaning, and restlessness. The Pain Rating Scale used was a non-verbal scale that indicated moderate pain with moaning and restlessness. The Plan/Recommendations were to monitor pain as indicated, administer pain medications as ordered, manage the resident's pain within acceptable level, notify the physician for any changes in condition as indicated, monitor effectiveness of pain medications, and document as indicated. The section for "Intensity of Pain" for pain at worst and tolerable level of pain, was blank.
A review of the Pain Assessment Flowsheet dated from October 1, 2009, to October 21, 2009, indicated Resident 1 received Norco pain medication at least 34 times. The location of pain was at the right leg with a pain level rating between 7/10 or 8/10 (on a pain rating scale of 0 to 10, with 0 as no pain and 10 as the worst possible pain). It was consistently documented in October 2009, that Resident 1?s pain rating after medication was 1/10.
A review of Resident 1?s medical record on March 3, 2011, with the Director of Nursing (DON), revealed there was no documented evidence that the resident's fluid intake was consistently monitored by means of an Intake and Output (I&O) record. The DON could not provide documentation that the resident received an adequate amount of fluids of 1609 cc free water, as recommended by the Registered Dietitian (RD) and in the resident?s care plan.
A review of the Medication Record dated October 2009, indicated Resident 1 received her ?routine? medications as ordered by the physician. There was no documentation that the MOM was administered in October 2009 to prevent constipation.
A review of Resident 1?s medical record on March 3, 2011, with the DON, that included the licensed Nurses Notes, indicated the resident was not consistently assessed for bowel habits, and monitored for the characteristics of the bowel movements including the frequency, color, amount, and consistency (hard, soft, formed, liquid) of the stool, in accordance with the facility?s policy and procedure and the resident?s care plan. The Certified Nursing Assistant ADL Sheet for October 2009, indicated on October 8, 2009, the 3 p.m. to 11 p.m. shift, October 13, 2009, the 3 p.m. to 11 p.m. shift, October 17, 2009, the 7 a.m. to 3 p.m. and 3 p.m. to 11 p.m. shifts, and October 20, 2009, the 3 p.m. to 11 p.m. shift, the frequency and amount of BM was not recorded accurately. There was no color of the stool documented, nor was the consistency documented to enable nursing to make a thorough assessment of Resident 1?s bowel habits, as indicated in the policy and procedure for ?Constipation? and in her care plan (to
ensure Resident 1 had soft formed stools).
A review of Resident 1?s undated History and Physical, (reviewed to be September 29, 2009 readmission) indicated Resident 1 did not have the capacity to understand and make decisions. The Physical Examination section for exam of the abdomen (Section F), was blank.
A review of the Nutritional Assessment progress notes dated October 12, 2009, indicated the diet ordered was mechanical soft NAS diet, and to cater to food preferences. The resident was able to express needs to Dietary Services Supervisor (DSS); continue to monitor weight and intake amount.
A review of the Certified Nursing Assistant ADL Sheet dated October 2009, indicated Resident 1 required being fed, and had an average amount of 53% consumption for breakfast, 58% for lunch, and 74% for dinner. On October 11 and 12, 2009, the resident refused breakfast. There was no documentation to indicate the resident was assessed as to why she refused her breakfast.
A review of the License Nurse Record dated October 22, 2009, indicated at 7:30 a.m., Resident 1 was awake, was served breakfast, ate and tolerated 40 % of food served; the resident remained confused and disoriented with episodes of screaming and yelling, no signs of pain noted. The resident was provided with incontinent care by her certified nursing assistant (CNA). At 11 a.m., the resident continued to have episodes of ?yelling and screaming.? The charge nurse ?ascertained? for behavior; no ?obvious? signs of pain noted.
On October 22, 2009, at 2:25 p.m., during rounds, the License Nurse Record documentation indicated Resident 1 was noted to have diminished response. The vital signs taken were as follows: temperature of 98 degrees Fahrenheit, pulse of 114 beats per minute (normal range is 60 to 100), blood pressure of 82/59 (normal reference is 120/80), and oxygen saturation of 86 % (normal reference range of 95% to 100%). The resident?s skin was cold and clammy. Ten liters of oxygen were administered via mask, and the resident?s oxygen saturation went up to 96 %; lung sounds were clear to auscultation (listen to with a stethoscope), no coughing noted. Bowel sounds were present to all four quadrants (bowel sounds have to be listened to for 5 minutes per section of the quadrant for a thorough assessment. There were no characteristics of the bowel sounds documented, such as hyperactive). No distention noted. The resident had a ?small BM early this morning during care.?
There were no identifying characteristics documented for Resident 1?s BM (such as the color and/or if formed, hard, soft, runny, or watery), as indicated in the facility?s policy and procedure, and in the care plan intervention to ensure soft formed BM. There was no documented evidence the licensed nurse assessed the reason for the resident's screaming and yelling to rule out pain. There was no documented assessment for mood/behavior management for Resident 1?s yelling/screaming, or that nonpharmacological interventions were attempted for the screaming/yelling, either for pain or for behavior reasons. There was no documentation the abdominal region was thoroughly assessed by inspection or palpation (use of the hands to touch).
A review of Resident 1?s medical record with the Director of Nursing (DON) on March 3, 2011, at 2:45 p.m., indicated:
1. The CNA flow sheet for October 2009 indicated Resident 1 was in bed ?B? on all three shifts, all but three occasions on the 3 p.m. to 11 p.m. shift, which did not increase physical activity to promote optimal bowel function as indicated in the resident?s care plan.
2. The resident?s intake was not monitored to ensure she was offered and consumed her daily fluid requirements as assessed by the RD. According to the flow sheets, Resident 1 never consumed 100% of her meals. She consumed an average of approximately 60% of her meals, which was far less than the assessed 1609 cc of free water daily (1609/60 = approximately 650 cc of fluids).
During the review and interview the DON was unable to answer why the resident was not given medication to prevent constipation, and why Resident 1?s intake and output was not monitored to enable nursing to thoroughly evaluate her status. She stated the incident occurred prior to her hire at the facility.
On March 4, 2011, at 10 a.m., during an interview with Staff Member 1 (SM 1), she stated most of the nurses were no longer working in the facility, therefore, interviews could not be conducted.
On March 4, 2011, at 10:30 a.m., during an interview with the Director of Staff Development (DSD), she stated there were no employee or in-service files for 2009; the DSD only had employee files from 2010 to the present.
The facility's undated policy and procedure titled, "Constipation" indicated the purpose was to maintain proper bowel function and minimize episodes of constipation. Residents are to be monitored daily for bowel movements by CNAs, who are to document observations in the nursing assistant notes. When a resident does not have a bowel movement within 48 to 72 hours, a licensed nurse is to be notified. The licensed nurse is to contact the physician and obtain orders. Physician's orders shall be carried out. If physician's orders prove ineffective, a licensed nurse shall assess the resident through observation of bowel sounds (presence/absence, quality), abdominal distention, nausea, vomiting and/or lack of appetite, abdominal discomfort/pain. The physician shall be notified for additional orders, which are to be administered. Nursing shall provide nutritional intervention as necessary. Director of Dietary Services shall assess for possible non-pharmaceutical intervention as necessary. Registered Dietitian is to
provide assessment as necessary.
A review of the GACH ER consultation reports indicated Resident 1 was admitted on XXXXXXX, 2009, in severe pain. She had an altered level of consciousness, was moaning in pain, and had a distended and taught abdomen, with no bowel sounds present. Resident 1 required endotracheal intubation, and X-rays showed she had a large amount of stool in her colon. Her survival rate was deemed to be zero, and she was a very high risk for any surgical intervention. Resident 1 died in the hospital on XXXXXXX, 2009, two days after her ER admission. Her ?Expiration Diagnosis? included perforated viscous, respiratory failure, and septic shock.
The facility failed to monitor, assess, and react promptly to Resident 1's change in bowel movement (stools) habits, to prevent constipation before it progressed to fecal impaction [a solid, immobile bulk of human feces that can develop in the rectum or colon (large intestine) as a result of chronic constipation and prolonged retention of feces], by failing to, including but not limited to:
1. Utilize Resident 1?s past diagnoses and treatment of rectal bleeding, constipation, and colon surgery, when conducting the initial assessment and plan of care.
2. Assess Resident 1's bowel habits, including monitoring the characteristics of the stools for frequency, color, amount, and consistency (soft, formed, hard, watery) of the stools, as indicated in the plan of care.
3. Implement Resident 1?s care plan interventions to prevent constipation, including inadequate fluid intake, immobility, and pain medications that could lead to suppression of defecation (bowel movements), constipation, and fecal impaction.
4. Consistently assess and monitor for side effects of consistent use of narcotic pain medications that had side effects of constipation.
5. Consistently monitor Resident 1?s intake and output (I&O) of fluids to ensure adequate hydration to prevent constipation.
As a result, Resident 1 was admitted to the GACH on XXXXXXX 2009, in severe pain with acute peritonitis from a severe bowel impaction. She was at the ER with an altered level of consciousness, moaning in pain, and had a distended abdomen. Resident 1 required endotracheal intubation at the ER. Her survival rate was deemed to be zero. Resident 1 was diagnosed with a perforated viscus and sepsis. Resident 1 died in the hospital on XXXXXXX, 2009, two days after her emergency room admission.
The above violation presented a substantial probability of death or serious physical harm and was a direct proximate cause of Resident 1?s death. |
| 920000030 |
SHADOW HILLS CONVALESCENT HOSPITAL |
920012530 |
B |
23-Aug-16 |
H7JF11 |
5587 |
483.12 (b) (1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies ? (i) The duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the nursing facility, and (ii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (b)(3) of this section, permitting a resident to return. 483.12 (b) (2) Bed-Hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section. 483.12 (b) (3) Permitting Resident to Return A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident ? (i) Requires the services provided by the facility; and (ii) Is eligible for Medicaid nursing facility services On 2/19/16, an unannounced visit was made to the facility to investigate a complaint related to the facility?s refusal to readmit Resident 1. Based on interview and record review, the facility failed to ensure its bed-hold and re-admission policies were implemented by failing to: 1. Hold the bed for seven days when Resident 1 was transferred to a general acute care facility (GACH) on 10/6/15 for evaluation and treatment of abdominal pain. 2. Allow Resident 1 to return and resume residence in the facility when the resident was ready for discharge from the GACH, within the seven day bed-hold period on 10/12/15. 3. Offer Resident 1 the next available bed when the seven day bed-hold period was exhausted and the resident was ready for discharge from the GACH and required skilled nursing facility level of care after 10/13/15. As a result, Resident 1 was sad and upset and remained at the GACH for over four months, until she was transferred to another facility. A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility on 2/1/13, with diagnoses of hypothyroidism (abnormally low activity of the thyroid gland), chronic obstructive pulmonary disease (lung disease that makes it hard to breathe) and schizoaffective disorder (mental disorder characterized by abnormal thought processes and deregulated emotions). The Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 10/6/15, indicated Resident 1 was alert, required extensive assistance during transfer, walking, dressing, eating, toilet use, personal hygiene, and bathing. A review of the Licensed Personnel Weekly Progress Notes dated 10/6/15, at 9:45 a.m., indicated Resident 1 was picked up by an ambulance and transferred to a GACH due to abdominal pain. On 10/13/15, at 8:56 a.m., the facility staff notified Resident 1's conservator that the seven day bed-hold had expired and the facility would no longer re-admit the resident. A review of the physician's order dated 10/6/15, at 9 a.m., indicated to transfer Resident 1 to the GACH due to abdominal distention and seven day bed-hold. On 2/19/16, at 8:30 a.m., during an interview, the GACH social worker (SW 1) stated she spoke to the director of nursing (DON) on 10/12/15, at 11 a.m., informing her the GACH would be transferring Resident 1 back to the facility on 10/13/15. The DON told SW 1 the facility would not re-admit Resident 1 because the resident was difficult to take care of. On 2/19/16, at 9 a.m., during a telephone interview, Resident 1 stated the facility staff promised to readmit her if she did not pass the seven day bed-hold. Resident 1 stated she was mad and upset because the facility staff kept stringing her along, giving her false hope. Resident 1 stated she had resided at the facility for years, considered it her home, and was sad to know the DON would not take her back. The facility?s policy on Admission, Transfer, Discharge Rights, addressed the seven day bed-hold and permitting the resident to return to the facility as per regulations. On 2/19/16, at 11:30 a.m., during an interview, the DON stated they would not readmit Resident 1 and she no longer wanted to discuss the issue. The facility failed to ensure its bed-hold and re-admission policies were implemented by failing to: 1. Hold the bed for seven days when Resident 1 was transferred to a general acute care facility (GACH) on 10/6/15 for evaluation and treatment of abdominal pain. 2. Allow Resident 1 to return and resume residence in the facility when the resident was ready for discharge from the GACH, within the seven day bed-hold period on 10/12/15. 3. Offer Resident 1 the next available bed when the seven day bed-hold period was exhausted and the resident was ready for discharge from the GACH and required skilled nursing facility level of care after 10/13/15. As a result, Resident 1 was sad and upset and remained at the GACH for over four months, until she was transferred to another facility. The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 920000289 |
SYLMAR HEALTH AND REHABILITATION CENTER |
920012679 |
A |
18-Jan-17 |
ODDW11 |
15628 |
F224 ?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. F323 CFR 42 ?483.25 (h)(1)(2) 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. H&SC ? 1418.6. No long-term health care facility shall accept or retain any patient for whom it cannot provide adequate care. Welfare and Institutions Code ? 5325.1. Persons with mental illness have the same legal rights and responsibilities guaranteed all other persons by the Federal Constitution and laws and the Constitution and laws of the State of California, unless specifically limited by federal or state law or regulations. No otherwise qualified person by reason of having been involuntarily detained for evaluation or treatment under provisions of this part or having been admitted as a voluntary patient to any health facility, as defined in Section 1250 of the Health and Safety Code, in which psychiatric evaluation or treatment is offered 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 mental illness shall have rights including, but not limited to, the following: (c) A right to be free from harm, including unnecessary or excessive physical restraint, isolation, medication, abuse, or neglect. Medication shall not be used as punishment, for the convenience of staff, as a substitute for program, or in quantities that interfere with the treatment program. 22 CCR ? 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. 22 CCR ? 72455. Special Treatment Program Service Unit - Abuse and Corporal Punishment. Patients shall not be subjected to verbal or physical abuse of any kind. Corporal punishment of patients is prohibited. Patients shall not discipline other patients. 22 CCR ? 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: (10) To be free from mental and physical abuse. The facility failed to provide a safe environment with adequate supervision to ensure Resident 2 was safe from physical abuse by Resident 1, who had a history of aggressive behavior. Resident 1 punched Resident 2 in the head, which knocked Resident 2 to the floor and caused him to have a seizure (altered consciousness), with sustained lacerations (cuts) to the left and right sides of his scalp. The facility also failed to protect Resident 2 from injuries by failing to implement Resident 1's care plan and follow its policy on Behavior Management, by failing to place Resident 1 in the "Evaluation Room" (a private room where staff can meet with and evaluate a resident), away from other residents, to identify the reasons for his agitation and/or aggression, and to provide 1:1 (one on one) or every 15-minute (q15) supervision, when Resident 1's aggressive behavior was escalating, in an attempt to prevent injuries to other residents. As a result, Resident 2 was assaulted, required ten stitches to his head, had an estimated blood loss of 350 milliliters (ml), and had the potential for further head trauma from the assault and fall. An entity reported incident (ERI) dated August 12, 2014, indicated Resident 2 was standing in the doorway of his room when Resident 1 approached him with no warning and punched him with a closed fist on the left side of his head. Resident 2 fell to the floor, and possibly hit his head on surrounding furniture or the floor. Resident 2 then had a seizure, and had blood on his head and lacerations on both the left and right sides of his scalp. An unannounced visit to the skilled nursing facility (SNF) was conducted to investigate this ERI. According to the Admission Record, Resident 2 was admitted to the facility on XXXXXXX, with diagnoses that included depression, paranoid schizophrenia (delusion or false belief that somebody is plotting against them), and seizure disorder. The Minimum Data Set Assessment (MDS- an assessment and care screening tool) dated July 3, 2014, indicated Resident 2 had no physical or behavioral symptoms towards others. He was noted to have disorganized thinking, and was inattentive. A review of the Licensed Nurses' Note dated August 10, 2014, at 1:30 p.m., indicated Resident 2 was standing in the North hallway in the doorway of his room when a Certified Nursing Assistant (CNA 1) observed Resident 1 approach Resident 2, and without warning, punched him with a closed fist, and then ran to his room. Resident 2 fell to the floor. Although CNA 1 saw the resident fall to the ground, it was unclear if Resident 2 hit his head on the surrounding furniture or the floor. CNA 1 called for assistance immediately and nursing staff came to assist and observed Resident 2 on the floor having a seizure. His breathing was labored, pupils dilated and non-reactive to light. Resident 2 was non-responsive to verbal or tactile (touch) stimuli. Staff turned the resident to his left side to ease his breathing. The resident was bleeding from his head. Lacerations were noted on both sides of the head on the scalp area, each laceration was less than an inch in length and two millimeters in width. The bleeding was controlled with gauze and pressure was applied. The estimated blood loss was 350 ml. Resident 2 was transported to the general acute care hospital (GACH) emergency room by Emergency Medical Service (EMS) for stabilization and further treatment of the head injuries. He was admitted to the hospital with diagnoses of seizures and low sodium. The Licensed Nurses' Note dated August 11, 2014, at 6:40 p.m. indicated staff from the GACH had called to report Resident 2 received 5 staples to the left side of his head, and 5 staples to the forehead. Resident 2 was readmitted to the SNF at 6:30 p.m., on XXXXXXX with his head wrapped in gauze. A review the Interdisciplinary Team (IDT) notes dated August 11, 2014, indicated Resident 2 was sent to the GACH for evaluation after a peer assaulted him. The IDT note dated August 14, 2014, indicated Resident 2 stated Resident 1 hit him, and he did not know why. On September 17, 2014, at 5:01 p.m., during an interview, Resident 2 who was alert, oriented and able to respond to questions with slow speech, stated he did not remember where the incident happened or identify the resident who hit him by name, but did remember he was wearing a blue shirt. According to the Admission Record, Resident 1 was admitted to the facility on XXXXXXX, with diagnoses that included schizoaffective disorder (mental disorder characterized by abnormal thought processes and deregulated emotions), polysubstance (drug) dependence, and obesity. Resident 1 had been in a psychiatric hospital from November 19, 2013, to June 5, 2014. A review of Resident 1's Admission Psychological Assessment for Free-Standing State Hospital dated XXXXXXX indicated Resident 1 was admitted from another GACH due to symptoms of mental illness and threatening/demanding behavior. The section "Recommendations for Management" indicated since Resident 1 is rated "high violence risk", staff should be vigilant when the resident begins to engage in aggressive behavior since he tends to quickly escalate. On XXXXXXX the facility admission acceptance form indicated Resident 1 was denied admission to the facility. The concerns at that time indicated the resident had a high potential for aggressive behavior and that the facility would reconsider after the annual inspection had passed. An undated Referral Assessment Form provided by the SNF from San Bernardino, indicated Resident 1's present condition and behavior to be loud and demanding to staff. Resident 1 had made verbal threats, and a peer reported Resident 1 hit him on the side of the head, which Resident 1 admitted he did. The last incident was on March 17 (no year) when he charged at a doctor and was physically removed. The Minimum Data Set (MDS), an assessment and care screening tool, Care Area Assessment Documentation Notes dated June 11, 2014, indicated Resident 1's judgement was impaired secondary to his thought disorder and lack of insight (which leads to poor decisions). His mood and behavior patterns were indicated by negative statements, repetitive verbalization, and persistent anger with himself and others. A review of Resident 1's care plan dated June 12, 2014, indicated the concern of poor impulse control as evidenced by hostile verbal outbursts and making verbal threats in the community. The goal was for the resident not to display any aggressive or assaultive behavior, during the next month. The intervention included to suggest the "Evaluation room" if Resident 1 appears to be escalating, and attempt to engage in discussion with a view to identify the antecedents of agitation. There was another concern for thought disorder as evidenced by responding to auditory hallucinations (hearing voices or other noises not there). The goal was for Resident 1 not to respond to internal stimuli during the next month. The intervention included if Resident 1 expressed he was experiencing any "Command type" hallucinations, staff were to suggest the "Evaluation room" and notify nursing staff. While in the Evaluation room, staff would attempt to determine the content and possible risk of injury to self and others. A review of Resident 1's Licensed Nurses' Notes dated July 23, 2014, July 26, 2014, August 6, 2014, August 9, 2014, and August 10, 2014, indicated there was no evidence staff had placed him in the Evaluation room when he exhibited an increase in hallucination and behavior problems, to determine the intent or risk of injury to himself or to others, in accordance with his plan of care. The Licensed Nurses' Note records indicated the following: 1. On July 23, 2014 at 8:30 p.m., Resident 1 was noted to be agitated, yelling to peers in the west yard. He was noted to be hostile; redirection was given three times but was ineffective. He was given Ativan (medication used for anxiety). 2. On July 26, 2014, at 9:30 a.m., Resident 1 presented with agitation yelling and screaming for no apparent reason. Verbal redirection was attempted but instead the resident requested and was given Ativan. 3. On August 6, 2014, at 4: 00 p.m., Resident 1 came to the nurse station and requested medication for agitation manifested by pacing around in the hallway. He was verbally redirected without success and was given Thorazine (medication used for behavioral problems). 4. On August 9, 2014, at 6:00 p.m., Resident 1 was noted to be agitated again yelling in his room. Redirection was given "with no effect". He was given Thorazine. 5. On August 10, 2014 at 1:30 p.m., Resident 1 approached Resident 2 while he was standing in the door way of his room, and punched him on the left side of his head with a closed fist then ran to his room. When interviewed, Resident 1 indicated he did not know why he did it. He did say "They sent this little guy to mess with me." Resident 1 was noted to be delusional, the psychiatrist was notified and ordered to place Resident 1 on one to one (one staff dedicated to directly observe) for his aggressive behavior and verbal threat. Resident 2 was offered Thorazine. On September 17, 2014, at 10 a.m., during an interview with Registered Nurse (RN) 1, she stated Resident 1 and Resident 2 were located on the same unit. Resident 1's medical record was reviewed with RN 1. She could not provide documented evidence that staff had implemented Resident 1?s care plan intervention to utilize the Evaluation room, prior to Resident 2?s assault, when Resident 1 had escalating behaviors. There was no evidence a care plan was developed for the potential for violence/assault, individualized to the needs of Resident 1, to prevent injuries/assaults to other residents, including Resident 2, even though Resident 1 had a long-time history of assaultive behavior, including towards family members. In an interview on September 17, 2014, at 4:14 p.m., the Program Director (PD) stated Resident 1 assaulted Resident 2. He also stated he was aware that Resident 1 had a history of hitting people prior to his admission to the facility and he had assessed Resident 1 at the GACH's psychiatric facility twice prior to the resident's admission. On September 17, 2014, at 5:13 p.m., during an observation and interview with Resident 1, he was calm but not sitting still in his chair. Resident 1 stated he pushed Resident 2 for no reason and that people were trying to get to him, so he pushed Resident 2. A witness statement from the certified nursing assistant (CNA 1), dated August 10, 2014, indicated the assault of Resident 2 took place at 1:30 pm. CNA 1 was in the North hallway while Resident 2 was standing in the doorway of his room. Resident 1 approached Resident 2 and punched him on the left side of his head with a closed fist, then ran to his room. Resident 2 fell to the floor and CNA 1 called for assistance. A review of the facility's undated policy and procedure titled "Behavior Management" included if a resident continues to be verbally or physically threatening, staff will suggest the Evaluation room to assist the resident in identifying antecedents (a preceding cause or event); and the resident would be placed on 1:1 or every 15-minute supervision. There was no documented evidence this policy was implemented when Resident 1 was exhibiting aggression, and when redirection was ineffective as indicated in the nursing notes. Therefore, the facility failed to provide a safe environment with adequate supervision to ensure Resident 2 was safe from physical abuse by Resident 1, who had a history of aggressive behavior. Resident 1 punched Resident 2 in the head, which knocked Resident 2 to the floor and caused him to have a seizure, with sustained lacerations to the left and right sides of his scalp. The facility also failed to protect Resident 2 from injuries by failing to implement Resident 1's care plan and follow its policy on Behavior Management, by failing to place Resident 1 in the "Evaluation Room", away from other residents, to identify the reasons for his agitation and/or aggression, and/or to provide 1:1 (one on one) or every 15-minute (q15) supervision, when Resident 1's aggressive behavior was escalating, in an attempt to prevent injuries to other residents. As a result, Resident 2 was assaulted, required ten stitches to his head, had an estimated blood loss of 350 ml, and had the potential for further head trauma from the assault and fall. These violations, jointly, separately, or in any combination, presented a substantial probability of death or serious physical harm to all residents in the facility, including Resident 2. |
| 970000097 |
SKYLINE HEALTHCARE CENTER-LOS ANGELES |
920012844 |
B |
28-Dec-16 |
F2LX11 |
5291 |
F 223 483.13 (b) Free from Abuse/Involuntary Seclusion The resident has the right to be free from verbal, sexual, physical abuse, corporal punishment, or involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. On 9/2/16, at 2:15 p.m., an unannounced visit was made to the facility to investigate an entity reported incident of resident abuse by a facility staff member. Based on interview, and record review, the facility failed to ensure Resident 1 had the right to be free from verbal, mental, and physical abuse, by failure to ensure Resident 1 was not verbally and physically abused by Certified Nursing Assistant 1 (CNA 1). As a result, CNA 1 slapped Resident 1 on both forearms and removed the call light away from the reach of Resident 1 causing the resident agitation and her body to shake when recalling the incident. A review of the admission record indicated Resident 1 was admitted to the facility, on xxxxxxx, with diagnoses including muscle weakness, history of falls, and hearing loss. The Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 7/12/16, indicated Resident 1 had no memory problems and was able to make her needs in another language than English. The resident was unable to walk, had limited movement on both legs, was incontinent of bowel and bladder functions and required extensive to total care and one-person physical assistance with eating, transferring, dressing and personal hygiene. A review of the Situation, Background, Appearance and Review (SBAR) communication form dated 8/18/16, indicated Resident 1, who was alert and oriented (person, place, time, and date), reported CNA 1 struck her on both forearms. The form indicated a head to toe assessment was conducted with no visible injuries and emotional support was provided to the resident. A review of the facility's investigation report of the alleged abuse the incident occurred at approximately 5:05 p.m. included several interviews with staff and residents. The director of nursing (DON) conducted an interview with Resident 1 on the same day of the allegation, 8/18/16, timed at 5:20 p.m. Resident 1 stated she called for help to change her incontinent brief and CNA 1 came to her room put away from her the call light and hit her three times on her forearms. The documentation indicated the resident was shaking and was very agitated during the interview. The DON also conducted an interview with CNA 1, the same day of the allegation at 5:45 p.m. CNA 1 stated Resident 1 kept calling and pressing the call light. CNA 1 denied hitting the resident but admitted removing the call light and placing it on the side table. The investigation report also included an interview with Licensed Vocational Nurse 1 (LVN) who was the medication nurse at the time of the incident. LVN 1 stated when he went to Resident 1?s bedside to administer her 5 p.m. medications, the resident pointed to the side of the bed where her call light was entangled with a power cord away from the resident?s reach. LVN 1 took the call light and gave it to the resident. The investigation report included interviews with other residents receiving care from CNA 1. Two of the residents indicated CNA 1 was rude and did not like to take care of them. On 9/2/16, at 2:15 p.m., during an interview, the DON stated CNA 1 was terminated and reported to the CNA Certification Section. According to the DON, the police informed her that during police interview, CNA 1 admitted to striking Resident 1's arms. On 9/2/16, at 2:45 p.m., during an interview through an interpreter, Resident 1, who was alert and oriented, stated that on the date of the incident, she turned on the call light for assistance with changing her incontinent brief. CNA 1 came into her room and without saying anything, took her call light and placed it out of her reach. Resident 1 then yelled out and tried to pull the call light back, but CNA 1 pulled it away from her, and slapped her hard on both forearms. The facility's policy and procedure titled, "Abuse - Prevention Program," revised 11/6/15, indicated the purpose of the program was to ensure the health, safety, and comfort of residents by preventing abuse and mistreatment. The facility does not condone any form of resident abuse, neglect and/or mistreatment, and develops facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment. The policy indicated the administrator as abuse prevention coordinator was responsible for the coordination and implementation of the facility's abuse prevention policies and training. The facility failed to ensure Resident 1 had the right to be free from verbal, mental, and physical abuse, by failure to ensure Resident 1 was not verbally and physically abused by Certified Nursing Assistant 1 (CNA 1). As a result, CNA 1 slapped Resident 1 on both forearms and removed the call light away from the reach of Resident 1 causing the resident agitation and her body to shake when recalling the incident. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1. |
| 970000099 |
SOLHEIM LUTHERAN HOME |
920012856 |
A |
9-Jan-17 |
YP7Z11 |
7368 |
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 5/26/16, at 10:25 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Resident 1 sustaining a fall at the facility resulting in a left hip fracture. Based on interview, and record review, the facility failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and failed to ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent falls and injuries, including: 1. Failure to ensure Resident 1, who was assessed as high fall risk due to confusion and history of falls, was supervised to prevent unassisted transfers. 2. Failure to monitor the use of the alarm while in bed and wheelchair to ensure its proper use. 3. Failure to ensure proper functioning of Resident 1?s wheelchair alarm to promptly notify staff of unassisted transfers to prevent falls and minimize injuries. 4. Failure to evaluate effectiveness of the use of the personal alarm in order to develop new and more effective interventions to prevent falls and minimize injuries. 5. Failure to develop comprehensive policies and procedures for fall prevention including the maintenance and use of personal (bed or wheelchair) alarms. As a result, Resident 1 fell sustaining a left hip fracture and pain to the left leg requiring transfer to a general acute care hospital (GACH) for evaluation and treatment. A review of the clinical record indicated Resident 1 was admitted to the facility on XXXXXXX, with diagnoses including unstable angina (chest pain), shortness of breath, hypertension (high blood pressure) and dementia (decline in mental ability severe enough to interfere with daily life). The Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 2/24/16, indicated Resident 1 was confused, required limited assistance with one person physical assistance with transfers in and out of bed, chair, toilet and with personal hygiene. Resident 1 was unable walk, used a wheelchair as mobility device, and needed supervision with bed mobility. According to the Fall Risk Assessment form dated 2/18/16, a score of 10 or more represented a high fall risk and Resident 1 scored 11. The form indicated Resident 1 had intermittent confusion and required the use of a wheelchair as assistive device for gait or balance. A care plan developed on 11/18/15, for orientation/safety/fall prevention, indicated Resident 1 was at risk for falls due to confusion related to dementia, anxiety, and history of falls (on 3/19/16, 4/5/16, and 5/18/16). The approaches included the use of a personal alarm while in wheelchair and in bed, frequent checks for proper wheelchair positioning, and repositioning as needed. On 3/21/16, the physician's ordered Resident 1 to have a personal alarm while in bed or wheelchair for safety and fall prevention. A review of the facility's interdisciplinary notes dated 5/18/16, timed at 6:50 p.m., indicated Resident 1 had an unwitnessed fall, was lying on the floor on her left side along the hallway without her wheelchair. Resident 1 complained of pain upon movement of the hip and the left leg rated 8/10 (pain scale from zero to 10, zero represents no pain and 10 the most severe pain) and Norco (narcotic pain medication) was given to the resident. Resident 1 was unable to move her left leg due to pain. The physician was notified and ordered an urgent x-rays of left hip/leg. On 5/19/16 at 1:21 a.m., the x-rays result indicated an acute left intertrocanteric (hip area ? the upper part of the thigh bone) fracture with impaction and varus angulation (deformity in which an anatomical part is turned inward toward the midline of the body to an abnormal degree). The physician when informed ordered to transfer the resident to a general acute care hospital (GACH) for evaluation and treatment. There was no documentation addressing the presence of the wheelchair alarm at the time of the fall. There was no documentation to indicate Resident 1?s alarm was properly functioning or if it went off at the time the resident stood up. On 5/26/16, at 11:45 a.m., during an interview, Assistant Director of Nursing (ADON) stated Resident 1 was at risk for falls, had history of falls, and needed a personal alarm to alert the staff when the resident attempted unassisted transfers. The ADON did not know why the alarm did not go off, if the alarm was properly working, or if the resident had the alarm at the time of the fall incident. On 5/26/16, at 1:40 p.m., during an interview, Restorative Nursing Assistant 1 (RNA 1) stated Resident 1 was alone in the hallway, looked very tired, and then, fell. RNA 1 stated she did not see or hear any personal alarm. On 6/1/16, at 11:20 a.m., during an interview, the Director of Nursing (DON) stated she did not see the personal alarm with Resident 1 when she had the fall on 5/18/16. The DON confirmed no one was in the area to supervise Resident 1 while in the hallways. The DON stated the facility did not have written guidelines on fall prevention and management or the use of personal alarm. The facility failed to provide its residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, and failed to ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent falls and injuries, including: 1. Failure to ensure Resident 1, who was assessed as high fall risk due to confusion and history of falls, was supervised to prevent unassisted transfers. 2. Failure to monitor the use of the alarm while in bed and wheelchair to ensure its proper use. 3. Failure to ensure proper functioning of Resident 1?s wheelchair alarm to promptly notify staff of unassisted transfers to prevent falls and minimize injuries. 4. Failure to evaluate effectiveness of the use of the personal alarm in order to develop new and more effective interventions to prevent falls and minimize injuries. 5. Failure to develop comprehensive policies and procedures for fall prevention including the maintenance and use of personal (bed or wheelchair) alarms. As a result, Resident 1 fell sustaining a left hip fracture and pain to the left leg requiring transfer to a GACH for evaluation and treatment. 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. |
| 920000011 |
SAN FERNANDO POST ACUTE HOSPITAL |
920013218 |
A |
7-Jun-17 |
QBO212 |
10507 |
?483.25(d)
(e) Incontinence.
(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.
(2)For a resident with urinary incontinence, based on the resident?s comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident?s clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident?s clinical condition demonstrates that catheterization is necessary and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.
(3) For a resident with fecal incontinence, based on the resident?s comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
On April 25, 2017, at 8:20 a.m., during unannounced first revisit recertification survey, Resident 1 repeated urinary tract infection (UTI - an infection in any part of the urinary system, the kidneys, bladder or urethra) was investigated.
Based on observation, interview, and record review, the facility failed to ensure a resident who enters the facility with an indwelling catheter is assessed for removal of the catheter as soon as possible unless the resident?s clinical condition demonstrates that catheterization is necessary and resident received appropriate treatment and services to prevent urinary tract infections, including:
1. Failure to ensure Resident 1, who had an indwelling urinary catheter (soft tubing inserted in the bladder to drain urine outside the body), was evaluated for the continued need of the urinary catheter to ensure the use of the catheter was necessary due to the resident?s clinical condition.
2. Failure to ensure Resident 1 received the assessed daily estimated fluid needs of 1675 milliliters (ml) to 2070 ml per day as indicated in the Medical Nutrition Therapy Assessment, in order to maintain sufficient hydration.
3. Failure to implement plan of care interventions by not providing Resident 1 with proper incontinent care, to decrease risk of UTI and by not monitoring and reporting to the physician the presence of sediments in the urine.
These deficient practices resulted in Resident 1 repeated UTIs by April 19, 2017, unnecessary discomfort due to indwelling catheter used and placed the resident at risk of health complications.
On April 25, 2017 at 8:20 a.m., during an observation in the presence of licensed vocational nurse 1 (LVN 1), Resident 1 was lying in bed, awake, alert, and oriented to person and place. During a concurrent interview, Resident 1stated she wished she did not have the indwelling urinary catheter and did not like the way the catheter felt. LVN 1 explained Resident 1 had an indwelling urinary catheter because of a diagnosis of neurogenic bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition).
A review of the admission record indicated Resident 1 was initially admitted to the facility on XXXXXXX 2013 and the most recent readmission from general acute care hospital (GACH) was XXXXXXX 2017, with diagnoses including sepsis (a potentially life-threatening complication of an infection that occurs when chemicals released into the bloodstream to fight the infection trigger inflammatory responses throughout the body) secondary to UTI and acute cystitis (inflammation of bladder).
A review of the Minimum Data Set (MDS - a standardized comprehensive assessment and care planning tool) dated April 11, 2017, indicated Resident 1 was able to communicate, required extensive assistance with personal hygiene, and was totally dependent on staff for toilet use. The MDS also indicated the resident had an indwelling urinary catheter and was always incontinent (no control) of bowel function.
A review a care plan dated April 4, 2017, developed for Resident 1?s potential for recurrence of UTI/chronic UTI, had a goal for the resident to remain free from signs and symptoms or complications related to UTI and the interventions included assess/record/report to physician as needed signs and symptoms of UTI (blood in urine, foul odor, and cloudy urine); assist with perineal (between the vaginal opening and the rectum) care as needed and remind to wipe front to back; check at least every two hours for incontinence and wash, rinse and dry soiled areas.
A care plan initiated on April 4, 2017, for Resident 1?s indwelling urinary catheter use secondary to neurogenic bladder, had a goal for the resident's bladder to be adequately emptied without complication as evidenced by no bladder distention, pain, and no signs and symptoms of UTI for three months. The interventions included monitor urine for sediment (solid matter), cloudy, odor, blood, and amount; report any of the above or fever promptly to the physician; and provide good perineal care.
A review of the Medical Nutrition Therapy Assessment dated April 12, 2017, indicated Resident 1?s daily estimated fluid intake requirement was 1675 to 2070 milliliters (ml).
A review of a urine culture (a method to grow and identify bacteria that may be in the urine) result dated April 22, 2017, indicated greater than 100,000 colony-forming unit (cfu)/milliliter (ml) Escherichia coli (E. coli- bacteria found in the environment, foods, and intestines of people and animals). In general, the isolation of greater than 100,000 cfu/mL of a urinary microorganism that can cause a disease is indicative of urinary tract infection, Mayo Clinic).
A review of the physician?s orders indicated Resident 1 was receiving antibiotic therapy since April 19, 2017, for UTI and would be completed on April 29, 2017.
A review of the intake and output (I&O) record from April 4, 2017 to April 24, 2017, indicated the resident did not meet her daily estimated fluid intake, average fluid intake 1150 to 1300 ml per day. There was a daily average of 425 ml fluid deficit from the minimum estimated fluid intake of 1675 ml.
On April 25, 2017 at 3:40 p.m. during another observation, Resident 1 had sediments in the urinary drainage tubing, indicative of insufficient fluid intake or a sign of UTI.
On April 25, 2017 at 4:30 p.m., during an interview and record review, the Assistant Director of Nursing (ADON) stated each week, the nursing staff was expected to evaluate the resident I&O record, compare the total fluid intake against the dietitian's recommendation, and notify the dietitian if the resident did not meet the dietitian's recommendation for daily fluid intake. The ADON was unable to provide documented evidence that nursing staff addressed the inadequate fluid intake and the dietitian and the physician were made aware.
On April 26, 2017 at 10:10 a.m., during Resident 1's incontinence care observation, CNA 1 opened the resident's incontinence brief. During incontinence care, CNA 1 used a wipe and left it in the perineal area until placing the incontinent brief. CNA 1 did not clean the perineal area and buttocks prior to placing a clean incontinence brief. CNA 1 did not change the soiled gloves before handling the clean linens and clean incontinence brief. Resident 1 was observed had sediments in the urinary drainage tubing.
On April 26, 2017 at 2:38 p.m., during an interview and concurrent record review, LVN 1 stated the resident was transferred to the GACH (on March 31, 2017) for a urology consultation because of the recurring UTIs; however, LVN 1 was unable to find the urology consultation report from the GACH. The clinical record had no documentation to indicate the continued use of the indwelling catheter was evaluated or the diagnosis of neurogenic bladder. There was no documentation in the nursing notes regarding the sediment observed in the resident's urinary catheter tubing on April 25, 2017 at 3:40 p.m., and April 26, 2017 at 10:10 a.m.
On April 28, 2017 at approximately 4 p.m., the Medical Record Director stated the facility attempted to obtain the urology consultation report from the GACH, but was told there was none available.
A review of the facility revised policy dated November 2016, titled "Foley (brand name) Catheter," indicated that all residents admitted with Foley Catheter are to be evaluated for its medical necessity. If there is a medical condition for the Foley Catheter, ensure there is an order in place for it and documentation concerning the medical condition. The medical condition and the Foley Catheter must be care planned. Encourage fluids and monitor for sign and symptoms of UTI.
The facility failed to ensure a resident who enters the facility with an indwelling catheter is assessed for removal of the catheter as soon as possible unless the resident?s clinical condition demonstrates that catheterization is necessary and resident received appropriate treatment and services to prevent urinary tract infections, including:
1. Failure to ensure Resident 1, who had an indwelling urinary catheter, was evaluated for the continued need of the urinary catheter to ensure the use of the catheter was necessary due to the resident?s clinical condition.
2. Failure to ensure Resident 1 received the assessed daily estimated fluid needs of 1675 milliliters (ml) to 2070 ml per day as indicated in the Medical Nutrition Therapy Assessment, in order to maintain sufficient hydration.
3. Failure to implement plan of care interventions by not providing Resident 1 with proper incontinent care, to decrease risk of UTI and by not monitoring and reporting to the physician the presence of sediments in the urine.
These deficient practices resulted in Resident 1 repeated UTIs by April 19, 2017, unnecessary discomfort due to indwelling catheter used and placed the resident at risk of health complications.
The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious harm would result to Resident 1. |
| 920000011 |
SAN FERNANDO POST ACUTE HOSPITAL |
920013219 |
A |
7-Jun-17 |
QBO211 |
12662 |
?483.25(c)(2)(3) Increase/Prevent/Decrease in range of motion
(c) Mobility.
(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.
(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
On April 25, 2017 at 8:00 a.m., during an unannounced first revisit recertification survey made to the facility, Resident 1?s decline in range of motion was investigated.
Based on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion, maintain and/or prevent further decrease in range of motion, by failing to.
1. Failure to ensure Residents 1 was provided with complete range of motion (ROM - the extent of movement of a joint) exercises as ordered by the physician.
2. Failure to implement the facility's policy and procedure on Joint Mobility Assessment by not notifying the rehabilitation department of the decline in Resident 1's joint mobility.
3. Failure to ensure a trained licensed nurse performed resident joint mobility assessment
As a result, by April 25, 2017, Resident 1 had a decline in ROM of the following joints:
1. Left shoulder joint from minimal limitation (movement of 75 to 100 percent - %) to moderate limitation (movement of 50 to 75 %).
2. Left elbow from minimal limitation to moderate/severe (movement of 25 to 50%) limitation.
3. Left wrist from within normal limitation to moderate limitation.
4. Left hand/fingers from within normal limitation to minimal limitation.
A review of Resident 1's admission record indicated an initial admission to the facility on XXXXXXX 2015 and the most recent readmission dated XXXXXXX 2017, with diagnoses including hemiplegia (paralysis of one side of the body), and multiple sclerosis (a disease involving damage to the nerve cells in the brain and spinal cord).
A review of Resident 1?s physician's orders dated March 14, 2017, indicated RNA to perform assisted active range of motion (AAROM - there is participation of the resident) exercise on resident?s right upper and lower extremities five times a week as tolerated, and RNA five times a week for gentle passive range of motion (PROM - no participation of the resident) exercise with prolonged stretch as tolerated on the left upper and lower extremities.
A review of the Joint Mobility Assessment (JMA) dated March 14, 2017, indicated Resident 1 had minimal functional limitation on the left shoulder and left elbow (movement of 75 to 100%) and within normal limitation on left wrist and left hand/fingers.
A review of Resident 1's plan of care developed on March 14, 2017, indicated the resident was at risk for decrease in ROM on both left and right upper and lower extremities. The goal was to maintain the resident's current ROM on the right and left upper and lower extremities. The care plan interventions included to provide RNA exercise program five times a week, provide AAROM exercises as tolerated to the right upper and lower extremities, and provide gentle PROM exercise with prolonged stretch as tolerated to the left upper and lower extremities.
A review of Resident 1's care plan developed on March 17, 2017, indicated the resident had joint mobility limitations to the left shoulder and both (left and right) ankles. The plan of care also indicated the resident was at risk for development of contracture due to immobility related to multiple sclerosis and left hemiplegia. The care plan goal was for the resident not to have further loss of ROM daily for 90 days. The care plan interventions indicated to provide ROM exercises under RNA program as ordered and monitor for pain or stiffness.
A review of the undated Stop and Watch (an early warning tool) form completed by Licensed Vocational Nurse 1 (LVN 1) and filed under the April 12, 2017, section of the RNA binder, indicated Resident 1 had plantar flexion (movement of the foot in which the foot or toes flex downward toward the sole) and decreased ROM to the left upper extremity. There was no documentation LVN 1 notified the rehabilitation department or the physician regarding Resident 1?s decline.
A review of Resident 1's Minimum Data Set (MDS - a standardized comprehensive assessment and care planning tool) dated April 17, 2017, indicated the resident was sometimes able to understand others and sometimes made him-self understood. The resident required extensive assistance with one person physical assistance with bed mobility, dressing, toilet use, and personal hygiene. The MDS also indicated the resident had no functional limitation in ROM.
The Restorative Nursing Weekly Summary notes for April 2017 indicated the resident fairly tolerated his ROM exercises, did not complain of pain, and did not refuse ROM exercises. The notes did not indicate changes in the resident's ROM.
On April 25, 2017 at 8:45 a.m. to 9 a.m., Restorative Nursing Assistant 1 (RNA 1) and RNA 2 were observed providing AAROM and PROM to Resident 1. RNA 1 and RNA 2 were observed to not fully performing AAROM and PROM as the physician ordered and indicated in the RNA Manual as follows:
1. Right and left upper extremity range of motion - RNAs 1 and 2 did not attempt and/or perform flexion and extension (bending and straightening) of the thumb, abduction and adduction (finger spreading) of the fingers, ulnar and radial deviation (moving wrist side to side) of the wrist, rotation (moving the upper arm toward the stomach and away from the stomach) of the arm, and supination and pronation (turning upside and downside) of the forearm.
2. Right and left lower extremity range of motion - RNAs 1 and 2 did not attempt and/or perform flexion and extension (toe bending and straightening) of the toes, inversion and eversion (sole of the foot is turned inward and outward) of the foot, and internal and external rotation (rolling entire leg outward and inward) of the leg.
On April 25, 2017 at 11:20 a.m., during an interview, the Director of Rehabilitation (DOR) stated the rehabilitation department provided RNA training to the CNA using the RNA Manual. The DOR also stated after completion of the RNA training, CNAs were expected to implement all the exercises learned in the manual with 15 to 20 ROM repetitions performed on each joint as tolerated.
On April 25, 2017 at 12:18 p.m., during an interview, RNA 2 stated Resident 1 tolerated the ROM exercises and the resident's joint mobility had improved.
On April 26, 2017 at 8:47 a.m. to 9:05 a.m., RNA 2 was observed providing AAROM and PROM to Resident 1. Resident 1 was lying in bed. RNA 2 did not provide the following exercises according to the undated RNA Manual provided by the facility:
1. Right and left upper extremity range of motion - RNA 2 did not attempt and/or perform abduction and adduction of the fingers, ulnar and radial deviation of the wrists, rotation of the arms, and supination and pronation of the forearms. RNA 2 did not perform at least 10 repetitions of the left thumb's flexion and extension and left shoulder abduction (palm up, arm is raised toward the ear).
2. Right and left lower extremity range of motion - RNA 2 did not attempt and/or perform inversion and eversion of the feet, and internal and external rotation of the leg. RNA 2 did not perform at least 10 repetitions of the plantar flexion (foot down) of the feet. RNA 2 did not perform flexion and extension of the right toes
On April 26, 2017 at 9:45 a.m., during an interview, LVN 1 stated one of the RNAs notified her of Resident 1's decline in ROM of the left shoulder. LVN 1 stated she assessed the resident's ROM in the presence of the RNA, noted the decline and notified the DOR and the resident's primary physician.
On April 26, 2017 at 10:05 a.m., during a follow-up interview, LVN 1 stated she completed a rehabilitation screening referral form on April 12, 2017, the day the decline in ROM was noted.
On April 26, 2017 at 10:35 a.m., during an interview, the DOR stated she received a screening referral on April 25, 2017, regarding Resident 1's decreased ROM but not earlier. The DOR explained a screening referral form had to be completed in order to screen the resident. The DOR stated she asked LVN 1 to complete a screening referral form on April 25, 2017. The DOR also stated the facility procedure for decline in ROM was for the licensed nurse to assess the resident and notify the physician and rehabilitation department. The rehabilitation department would then screen the resident on the date the referral is received.
On April 26, 2017 at 11 a.m., during an interview in the presence of the DOR, Registered Nurse 1 (RN 1) stated only RNs were trained to perform joint mobility assessment.
On April 28, 2017 at 8:50 a.m., during an interview, RN 2 stated she was the RN assigned to Station 1 on April 12, 2017. RN 2 stated she did not recall being notified of Resident 1's decline in ROM. RN 2 also stated she did not recall assessing Resident 1's joint mobility on April 12, 2017.
A review of the facility's revised policy and procedures dated November 2016, titled "Joint Mobility Assessment," indicated physical therapy screening or evaluations will be requested based on assessment results, ineffective interventions, or the development of complications requiring therapy expertise.
A review of the facility's undated Manual for Range of Motion indicates to use proper technique for range of motion; do full range of motion to end of range. The following are motions to be completed during ROM:
1. Abduction of the fingers include moving the fingers apart (spread fingers) and adduction is moving the fingers together.
2. Radial deviation is moving the hand sideways so that the thumb side of the hand is moved toward the forearm and ulnar deviation is moving the hand sideways so that the little finger is moved toward the forearm.
3. Flexion of the thumb is bending at all joints and extension is straightening the thumb.
4. Supination and pronation of the forearm is with the elbow at waist, bent to 90 degree angle, turning hand so palm is facing up and pronation is with the elbow at waist, bent to 90 degree angle, turning hand so palm is facing down.
5. Rotation is when the arm is at the side, turning the upper arm in so the hand moves toward his stomach and moving the upper arm so his hand moves away from his stomach.
6. Shoulder extension is returning arm downward to the side or neutral position after flexion. Flexion is moving the arm forward and upward until it is alongside the head.
7. Flexion of the toes is bending the toes toward the ball of the foot and extension is straightening the toes and pulling them toward the shinbone as far as possible.
8. Inversion is moving the foot so the sole of the foot is facing outward and eversion of the foot is moving the foot so the sole is facing inward.
9. Internal rotation of the leg is rolling the entire leg away from you so the knee cap is turned inward and external rotation of the leg is rolling the leg toward you so that the knee points outward.
The facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion, maintain and/or prevent further decrease in range of motion, by failing to.
1. Failure to ensure Residents 1 was provided with complete range of motion (ROM - the extent of movement of a joint) exercises as ordered by the physician.
2. Failure to implement the facility's policy and procedure on Joint Mobility Assessment by not notifying the rehabilitation department of the decline in Resident 1's joint mobility.
3. Failure to ensure a trained licensed nurse performed resident joint mobility assessment
As a result, by April 25, 2017, Resident 1 had a decline in ROM of the following joints:
1. Left shoulder joint from minimal limitation to moderate limitation.
2. Left elbow from minimal limitation to moderate/severe limitation.
3. Left wrist from within normal limitation to moderate limitation.
4. Left hand/fingers from within normal limitation to minimal limitation.
The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious harm would result to Resident 1. |
| 920000289 |
SYLMAR HEALTH AND REHABILITATION CENTER |
920013220 |
B |
24-May-17 |
ZZI111 |
7838 |
?483.25 (h) Accidents
The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.
On 2/22/17, at 9:05 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding resident?s safety.
Based on observation, interview, and record review, the facility failed to ensure the residents environment remains as free of accident hazards as is possible and that each resident receives adequate supervision to prevent injuries, including:
1. Failure to ensure Resident 1, who was known to be hoarding (excessive collecting) cigarette butts, was provided with the necessary supervision and assistance to prevent accidents.
2. Failure to implement the facility?s policy and procedure on Contraband Items, Smoking, and Locker Searches or Locker Checks by allowing Resident 1 to hoard cigarette butts and keep a lighter; by not documenting the locker checks; and by not conducting the locker checks more frequently than once a week.
3. Failure to develop a comprehensive plan of care with specific interventions to prevent Resident 1 from hoarding flammable items to prevent accidents and injuries.
As a result, on 2/20/17 Resident 1's mattress caught fire and Resident 1 sustained second degree burns (a more serious burn, the damage extends beyond the top layer of skin, causes the skin to blister and become extremely red and sore) to the left thumb, index and middle finger and to the right and left calves.
According to the Admission Face Sheet, Resident 1 was re-admitted to the facility, on XXXXXXX 14, with diagnoses including paranoid schizophrenia (a chronic mental disorder in which a person loses touch with reality and has false beliefs that a person or persons are plotting against them).
A review of the Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 8/10/16, indicated Resident 1 was alert, continuously had difficulty focusing attention, and had disorganized thinking.
A plan of care developed 11/14/16, and updated 2/14/17 for Resident 1?s hoarding trash evidenced by storing trash and cigarette butts in his room and in his pocket, had a goal for the resident not to hoard cigarette butts. The approaches included counselors to discuss the importance of rule compliance for both his progress and the safety of others; attempt to determine the nature of and how Resident 1 was obtaining contraband (any goods which are illicit or prohibited); and reward the resident if no contraband was found during search. The care plan did not indicate the frequency of the search for contraband.
Further record review revealed no documentation indicating staff attempted to determine how Resident 1 obtained the contraband or how often was the resident searched for contraband.
A review of the Interdisciplinary Progress Notes dated 2/20/17 late entry timed at 10:49 p.m., for 6 p.m., indicated Resident 1 was placed on one to one supervision related to burns to self and mattress, the physician was notified and ordered transfer to a General Acute Care Hospital (GACH) for evaluation. Resident 1 left at 7:15 p.m.
A review of the GACH Emergency Department (ED) Report, dated 2/20/17, at 9:05 p.m., indicated Resident 1 had second degree burns to both calves from a lighter, no measurement documented. The ED report indicated the wounds were dressed with Silvadene dressing (a medication used with other treatments to help prevent and treat wound infections in patients with serious burns).
Resident 1 returned to the facility at 10:30 p.m. with treatment orders for the second degree burn areas: right and left calves and left thumb, index and middle fingers.
On 2/22/17, at 9:15 a.m., Resident 1 was observed wearing a sweater with two burn holes and had dressings/bandages to the calves. Resident 1 was unable to recall the burn incident.
On 2/22/17, at 9:33 a.m., Resident 1's mattress was observed with a hole in it (about 3 inches in diameter). The hole was brown and the foam from the mattress was exposed.
On 2/22/17, at 10:10 a.m., during an interview, Floor Supervisor 1 stated residents were not allowed to have lighters in their possession; there were weekly ?Locker Searches? where the lockers, living space, beds, nightstands, and clothing pockets were searched. The last time Resident 1 had a Locker Search was on 2/16/17, four days prior to the fire incident. Floor Supervisor 1 stated he did not know where or how Resident 1 got a lighter.
On 2/22/17, at 10:05 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated, on the day of the incident (2/20/17), Resident 1 walked up to the nurses? station and informed the nurses that he had burned his left hand and fingers and both calves. A lighter was found in Resident 1's possession. LVN 1 did not know where or how the resident got the lighter. LVN 1 was unaware how often the floor supervisors were supposed to check the residents for contraband.
On 2/22/17, at 10:45 a.m., during an interview, Counselor 1 stated the counselors carry the lighters and monitor the residents while they are on their cigarette breaks.
On 3/16/17, at 1:30 p.m., during an interview, the Program Director stated Resident 1 hoarded cigarette butts in his pocket at times for the past two quarters (8/2016 to 2/2017) and the residents were supposed to empty their pockets when they returned from outside. Program Director also indicated Resident 1 was not searched every day and the Locker Searches were not documented.
A review of the facility's undated policy and procedure titled, "Contraband Items," indicated residents were not permitted to possess cigarettes, lighters, or matches in order to reduce potential harm.
A review of the facility's policy and procedure titled, "Smoking," dated 10/30/16, indicated residents were not allowed to carry cigarettes or lighting devices or store them in their personal spaces.
A review of the facility?s policy and procedure titled, ?Locker Searches and Locker Checks,? dated 11/11/08 and revised 2/20/17, indicated all residents will have their locker checked not less than one time per week unless otherwise indicated on the Patient Plan of Care. For those residents who require more frequent locker checks (due to hoarding items; hiding contraband; are known to engage in self-abuse behaviors as demonstrated by prior behavior within this facility, etc.) it will be documented on the patient plan of care. Floor Supervisors will maintain a log o the search and any contraband found.
The facility failed to ensure the residents? environment remains as free of accident hazards as is possible and that each resident receives adequate supervision to prevent injuries, including:
1. Failure to ensure Resident 1, who was known to be hoarding cigarette butts, was provided with the necessary supervision and assistance to prevent accidents.
2. Failure to implement the facility?s policy and procedure on Contraband Items, Smoking, and Locker Searches or Locker Checks by allowing Resident 1 to hoard cigarette butts and keep a lighter; by not documenting the locker checks; and by not conducting the locker checks more frequently than once a week.
3. Failure to develop a comprehensive plan of care with specific interventions to prevent Resident 1 from hoarding flammable items to prevent accidents and injuries.
As a result, on 2/20/17 Resident 1's mattress caught fire and Resident 1 sustained a second degree burns to the left thumb, index and middle finger and to the right and left calves.
The above violation had direct or immediate relationship to the health, safety, or security of Resident 1. |
| 920000289 |
SYLMAR HEALTH AND REHABILITATION CENTER |
920013336 |
A |
14-Jul-17 |
BOD711 |
12576 |
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.
F323
?483.25 (d) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
On January 11, 2017, at 3:05 p.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care.
Based on interview and record review, the facility failed to provide its residents the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and failed to maintain a safe environment free from hazards as is possible, including:
1. Failure to implement the facility?s policy and procedure on Contraband Items, by not checking Resident 1 and his belongings when returning back to the facility after a three-day leave.
2. Failure to effectively implement the facility?s policy and procedures on Locker Searches and Locker Checks by not conducting a weekly thorough check of Resident 1?s possessions and not finding a razor blade the resident kept in the drawer of his bedside table from October 20, 2016 to January 5, 2017.
3. Failure to implement the facility?s policy and procedures on Locker Searches and Locker Checks by not documenting in Resident 1?s plan of care and progress notes, contraband was found on January 3, 2017.
4. Failure to implement the facility's policy and procedures on Social Services Documentation, by not documenting Resident 1?s lack of progress toward established goals, increased delusions (inaccurate beliefs held by an individual), and increased paranoia (a thought process believed to be heavily influenced by anxiety or fear, often to the point of delusion and irrationality).
5. Failure to notify the psychiatrist of Resident 1?s increased delusions, after visiting Resident 1 on December 9, 2016, and recommending observing the resident for deterioration.
As a result, on January 5, 2017, at 8 a.m., Resident 1 cut his right wrist, with a razor blade he had for over two months, requiring transfer to a general acute care hospital (GACH), where 10 staples were applied to close the wound and Resident 1 was placed on a 72-hour hold due to danger to self.
A review of the clinical record indicated Resident 1 was originally admitted to the facility (a locked facility for residents with mental illnesses) on December 20, 2005, with diagnoses including schizoaffective disorder (a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior).
A plan of care developed June 26, 2016 for Resident 1?s mood disorder manifested by feeling depressed, indicated the resident had reported feeling sad in the month of July, August, and September 2016. The care plan interventions included observing and responding to Resident 1's verbal and non-verbal expressions by active listening to show him he was respected and worthwhile and encouraging the resident to ask for assistance as necessary to ensure interactions to meet his needs.
A plan of care developed June 26, 2016 for Resident 1?s thought disorder manifested by delusional statements and disorganized speech, included in the interventions teaching cognitive (thinking) replacement strategies to interrupt or displace irrational thoughts. The care plan indicated Resident 1 remained paranoid about peers during the month of September 2016.
A review of the Minimum Data Set (MDS ? standardized assessment and care planning tool) dated September 19, 2016 and December 19, 2016, indicated Resident 1 had no memory problems, had depressed mood, feeling down or hopeless, and had sleep problems nearly every day prior to the assessment dates.
A review of the nursing notes indicated on XXXXXXX, 2016 Resident 1 left the facility for court appearance. Resident 1 returned to the facility three days later, on XXXXXXX 2016 at 1:57 p.m., in stable condition. The documentation did not indicate Resident 1 and his belongings were checked upon his return to ensure the resident was free of dangerous/contraband items.
A review of Resident 1's clinical dependency progress dated November 26, 2016, indicated Resident 1's refused to participate in the chemical dependency group sessions for the month of November, 2016.
A review of Resident 1?s psychiatric progress notes dated December 9, 2016 indicated the psychiatrist recommended observing Resident 1 for deterioration and bizarre behavior.
A review of the social services quarterly progress note dated December 26, 2016, indicated Resident 1 delusions had increased. There was no documented evidence the increased delusions were reported and discussed with the IDT (program director, director of nursing, psychiatrist, attending physician, and nursing staff).There was no documented evidence the licensed nurses notified the psychiatrist of Resident 1?s increased delusions (deterioration).
Although Resident 1?s progressive behavioral deterioration was documented by different staff from the IDT, there were no new interventions developed to improve the mood and behavior manifestation and prevent further deterioration of Resident 1?s mental condition. The plan of care addressing the resident?s mood and behavior, were not revised to ensure effective interventions.
A review of the IDT note dated January 5, 2017 indicated Resident 1 cut himself that morning and was at GACH 1 and most likely being admitted.
A review of GACH 1 clinical record indicated on January 5, 2017 at 9:11 a.m. Resident 1 had worsening depression, cut his left wrist in a suicidal attempt, and stated being tired of living.
According to GACH 1 psychiatric evaluation dated January 6, 2017 timed at 6:10 p.m., Resident 1 slit his right wrist with a razor blade. Resident 1 had ten staples on his right wrist, and was determined to be a danger to self. Resident 1 was placed on (involuntary) 72-hours hold, and was admitted to the behavioral unit.
According to a review of the facility's policy and procedures on Social Services Documentation dated October 30, 2016, social service progress notes shall be written quarterly and more often as resident's condition warrants to reflect the resident's progress toward established goals and to re-evaluate the treatment plan when appropriate, review and update care plans, in coordination with any IDT or care plan meeting, and at any time to document pertinent observations, condition changes, follow-up provided, or important events.
A review of the facility's policy and procedure dated October, 30, 2016 on Locker Searches and Locker Checks, indicated all residents will have their lockers checked by rehabilitation or nursing staff no less than one time per week unless otherwise indicated on the plan of care. Locker checks will be performed regularly to ensure residents are not in possession of prohibited items. Residents who require more frequent checks due to hoarding of items, hiding contraband, or are known to engage in self-abuse behaviors, as demonstrated by prior behavior within the facility, will be documented on the plan of care, on the monthly progress notes, and the quarterly review.
A review of the facility's undated policy and procedure titled, "Contraband Items," indicated residents are not permitted to bring or possess the following items unless permission is granted by the clinical director; sharp items (i.e. scissors, knives, razors, etc.). Staff is responsible for checking belongings when returning back from a visit and inappropriate items will be put into storage or sent with family members for safekeeping.
On January 11, 2017 at 4:16 p.m., during an interview, Social Services Designee 1 (SSD 1) stated Resident 1 became more paranoid with peers after he returned from the court appearance on October 20, 2016. SSD 1 stated Resident 1 decreased attendance in the chemical dependency and had been isolating. SSD 1 stated the social services staff meets on a weekly basis with the rehabilitation case managers, program director, and nursing staff, to discuss the resident needs and concerns. SSD 1 was unable to provide documentation Resident 1?s increased isolation, paranoia, and depressive mood were addressed during the weekly meetings.
On January 12, 2017 at 12:40 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1) stated on the day (January 5, 2017) Resident 1 was sitting in a wheelchair and was bleeding to the floor. When CNA 1 asked what he used to cut his wrist, Resident 1 responded a razor blade, but did not say where he got the blade.
On January 12, 2017, at 3 p.m., during an interview, the Director of Nursing (DON) stated the residents? rooms and their belongings are searched once a week for dangerous or prohibited items (contraband) as per facility?s policy. The DON stated there is a schedule for the search and Reside t 1?s last search was done on January 3, 2017. The DON stated the searches were not documented.
On January 12, 2017, at 3:10 p.m., during an interview Floor Supervisor 1 (FS 1) stated the counselors are responsible for the room and personal belonging searches. The team performs a daily visual check of all common areas and resident lockers. FS 1 stated two pens were found in Resident's 1's room on inspection on January 3, 2017, and were confiscated. Resident 1 having contraband was not care planned.
On January 12, 2017, at 4 p.m., during an interview, Resident 1 stated he brought the razor blade into the facility when he returned from his court appearance. Resident 1 explained he kept the razor blade in a plastic zip bag with a bar of soap and toothpaste inside the drawer of his bedside table. Resident 1 stated the staff goes through his belongings by looking in drawers and pockets of his stuff, but did not see the razor blade in his drawer.
On January 19, 2017, at 10 a.m., during an interview, Counselor 1 stated on January 3, 2017, they were short of staff and he completed the inspection alone, found the two pens but did not see the razor blade.
The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, and failed to maintain a safe environment free from hazards as is possible, including:
1. Failure to implement the facility?s policy and procedure on Contraband Items, by not checking Resident 1 and his belongings when returning back to the facility after a three-day leave.
2. Failure to effectively implement the facility?s policy and procedures on Locker Searches and Locker Checks by not conducting a weekly thorough check of Resident 1?s possessions and not finding a razor blade the resident kept in the drawer of his bedside table from October 20, 2016 to January 5, 2017.
3. Failure to implement the facility?s policy and procedures on Locker Searches and Locker Checks by not documenting in Resident 1?s plan of care and progress notes, contraband was found on January 3, 2017.
4. Failure to implement the facility's policy and procedures on Social Services Documentation, by not documenting Resident 1?s lack of progress toward established goals, increased delusions (inaccurate beliefs held by an individual), and increased paranoia (a thought process believed to be heavily influenced by anxiety or fear, often to the point of delusion and irrationality).
5. Failure to notify the psychiatrist of Resident 1?s increased delusions, after visiting Resident 1 on December 9, 2016, and recommending observing the resident for deterioration.
As a result, on January 5, 2017, at 8 a.m., Resident 1 cut his right wrist, with a razor blade he had for over two months, requiring transfer to a general acute care hospital (GACH), where 10 staples were applied to close the wound and Resident 1 was placed on a 72-hour hold due to danger to self.
The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious harm would result to Resident 1. |
| 940000117 |
SoCal Post-Acute Care |
940011129 |
A |
10-Dec-14 |
21M911 |
9699 |
72311(a) (1 (C) (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient?s condition On September 27, 2012, the Department received an entity reported incident (ERI) which indicated on September 25, 2012, at 12:15 a.m., a patient (Patient 1) was found bleeding from her arteriovenous shunt (AV shunt/ used as an access site for hemodialysis [process of removing waste and excess water from the blood, and is used as an artificial replacement for the loss of kidney function]). According to the ERI, pressure was applied, in an attempt to control the bleeding and vital signs were attempted, but the patient had none and 911 was called. At 12:20 a.m., September 25, 2012, the paramedics arrived and noted a moderate amount of bleeding, with continued pressure applied to the left arm AV shunt, but the patient was pronounced dead at approximately 12:20 a.m. Based on medical record review and interviews, the facility?s staff failed: 1. To develop a plan of care for the patient?s ?scratching AV shunt behavior.? 2. To update and or revise the existing care plan regarding the care of the AV shunt after the bleeding episode 24 hours prior to second incident of the patient scratching the AV shunt and bleeding out. 3. To assess Patient 1 timely after she had to return to the facility from the dialysis center after experiencing a change in condition. These failures resulted in Patient 1 removing her AV shunt dressing and scratching at the site on September 24, 2012, which the patient was found bleeding excessively and the dressing was observed off and on the floor. The staff applied pressure and stopped the bleeding and notified the physician. The next day, September 25, 2012, at 12:15 a.m., the patient was found again, with the dressing off and bleeding from the AV shunt site. The paramedics were called and Patient 1 was pronounced dead. An initial unannounced visit was made to the facility on October 5, 2012, and a follow-up visit on August 4, 2014, at 8:30 a.m. During an interview with the director of nursing (DON), when asked about the incident with Patient 1, she stated the incident happened during the 3-11 p.m. change of shift, on September 24, 2012. According to the DON, Staff A found Patient 1 in bed and she was bleeding from her left arm A/V shunt and the charge nurse for the 11 p.m.-7 a.m., (Staff B) was called for help. Staff B found Patient 1 in bed, non-responsive in a supine position (lying on her back), with active bleeding from the AV shunt site on her left arm. Staff C was in the room attempting to get the patient?s vital signs, unsuccessfully and Staff D called the paramedics.According to the patient?s medical record Face Sheet, Patient 1 was a 98 year-old female, who had a history of receiving hemodialysis 12 years prior to her admission to the facility on March 21, 2011. The patient?s diagnoses included end stage renal disease (ESRD/ kidneys stop working and requires dialysis or a transplant to live), anemia in ESRD (decreased amount of red blood cells due to damaged kidneys), with an arteriovenous fistula (direct connection of an artery to a vein, which provides an access for good blood flow for hemodialysis). A review of the physician?s orders, dated September 1, 2012 through October 16, 2012, indicated Patient 1 received hemodialysis three times a week, Mondays, Wednesdays, and Fridays. The order indicated the AV shunt dressing was to be changed at the dialysis center and no blood pressure or venipuncture performed on the left arm AV shunt site. The staff were to monitor the bruit and thrill (bruit-rushing sound indication access is working/thrill pulsation of the shunt), check for bleeding at AV shunt site and document every shift, and notify physician promptly of any changes. A review of a quarterly Minimum Data Set (MDS), a standardized assessment and care screening tool, dated June 15, 2012, indicated Patient 1 had good recall skills for daily decision making. According to the MDS, under Section O: Special Treatments and Procedures indicated the patient was receiving dialysis while in the facility. A care plan dated June 6, 2011, and revised on September 2012, titled, ?Potential for infection and complication of the left arm AV shunt.? The goal indicated Patient 1 would be free from infection and complication. The staff?s plan or approaches included to monitor for signs and symptoms, such as; redness, swelling, pain and tenderness and report to the physician. The plan of care also stipulated the AV shunt would be monitored for bleeding especially after dialysis treatment by observing/monitoring the bruit (swishing sound heard with a stethoscope over a blood vessel) and thrill (vibration felt over AV shunt) every shift document and call physician if bruit and thrill is absent. The staff was to observe/maintain no pressure or flexion on site of AV shunt or dialysis catheter every shift. A review of the multidisciplinary progress record, dated September 24, 2012, and timed at 1:20 a.m., indicated Patient 1 was found in bed bleeding from the AV shunt site, and with the dressing observed on the floor. When Patient 1 was asked by Staff B what happened she stated ?I scratched it,? indicating the AV shunt site. On October 5, 2012, at 12 noon, during an interview, Staff B stated the staff did not communicate to the dialysis center the amount of blood assessed by the night shift when Patient 1 removed the AV shunt dressing from her left arm. Another interview on October 5, 2012, at 12:45 p.m., Staff A stated, ?She (Patient 1) took off the bandage and there was a lot of bleeding so I called the charge nurse, it was too much blood. The patient was lying on her left side on September 24, 2012, after the incident, and the patient stated, ?I?m going to die with this.? A review of the plan of care for potential complications of the AV shunt, last re-evaluated in September 2012, the facility?s staff failed to revise/update the patient?s behavior of scratching at the AV shunt site and the staff approaches to prevent her scratching. On the morning of September 24, 2012, the patient was cleared by the physician to go to dialysis, after the bleeding incident earlier that morning, for treatment that morning. A review of the facility?s pre-assessment dialysis form, dated September 24, 2012, without a time, indicated Patient 1 scratched her left arm at AV shunt site resulting in bleeding. However, the facility did not inform the dialysis center or document on the pre-assessment dialysis form the amount of blood Patient 1 lost during the bleeding incident. According to a post-dialysis assessment, dated September 24, 2012, completed by the dialysis center, during the dialysis treatment, Patient 1 became nauseous, weak, and hypotensive (low blood pressure [93/62; normal reference range 120/80]) during the first hour of dialysis treatment and the treatment was stopped and oxygen was administered. The dialysis center notified the facility with initial plans to transfer Patient 1 to a general acute care hospital (GACH) for evaluation. Twenty-five minutes later, the dialysis center called the facility again and stated the patient was stable and would be returning to the facility. Patient 1 returned to the facility at 10:40 a.m., on September 24, 2012. A review of the facility?s nurse?s progress note, dated September 24, 2012, indicated the patient returned to the facility at 10:40 a.m. However, there was no documented evidence the patient was assessed by checking the patient?s vital signs until four hours later. There was also no documentation the staff was continuously assessing the needs of Patient 1 who received hemodialysis on an outpatient basis, as indicated by the delay of an assessment upon her return from the dialysis treatment after she had a change in condition. An interview with the DON on August 4, 2014, at 10:48 a.m., when asked why Patient 1?s vital signs were not assessed at 10:40 a.m., upon the patient?s returned from the dialysis center, she stated, ?The patient?s vital signs were not taken until 3 p.m.? A review of an article titled, Blood loss through AV fistula, by the International Journal of Nephrology, dated May 30, 2011, indicated acute blood loss through vascular access can be a life threatening problem. The article stresses the importance of vascular access monitoring and surveillance to prevent failure. It indicated one of reason for AV shunt bleeding included trauma. The article concluded patients with ESRD may lose blood from the AV fistula due to a variety reasons, but patient and staff education is important to avoid complications of access bleeding (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3118665/) The facility failed by not: 1. Developing a plan of care for the patient?s ?scratching A/V shunt behavior.? 2. Updating and or revising the existing care plan regarding the care of the AV shunt after the bleeding episode 24 hours prior to second incident of the patient scratching the AV shunt and bleeding out. 3. To assess Patient 1 timely after she had to return to the facility from the dialysis center after experiencing a change in condition. The above violations jointly, separately, or in any combination presented an imminent danger, that serious physical harm would result and was the direct cause of serious physical harm to Patient 1. |
| 940000042 |
SHORELINE HEALTHCARE CENTER |
940011134 |
B |
10-Dec-14 |
RKWZ11 |
5754 |
72523. Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure the patient related goals and facility objectives are achieved. On November 12, 2013 the Department received a complaint alleging, on November 8, 2013, a patient (Patient 1) eloped from the facility. The patient left the facility in a wheel chair and was not found until November 22, 2013, fourteen days after the patient eloped from the facility. The facility?s staff failed to report the patient?s elopement within 24 hours as indicated by State requirements and the facility?s policy and procedure of reporting elopements and missing patients.The above violation had a high probability that could have threaten the welfare, safety, or health of Patient 1. On July 28, 2014, at 2:30 p.m., an unannounced visit was made in the facility to conduct a complaint investigation. Based on interview and record review, the facility failed to meet the intent of this regulation by not: 1. Reporting Patient 1?s elopement from the facility within 24 hours as required by State law. 2. Following its policy and procedure of reporting and notifying the Department within 24 hours of an elopement or a missing patient. A review of Patient 1?s medical record indicated the patient is a 53-year old female who was originally admitted in the facility on November 9, 2007 from a general acute care Hospital (GACH) and re-admitted to the facility on April 25, 2011.The patient?s diagnoses included unspecified paralyses(loss of muscle function for one or more muscles cause of paralyses unknown), difficulty walking, schizophrenia unspecified (a chronic psychiatric disorder the nature of the schizophrenia is unknown), unspecified paranoia (a mental condition characterized by delusions of persecution nature of the paranoia unknown), diabetes type II (inability of the body to use insulin properly), and asthma (a chronic [long-term] lung disease that inflames and narrows the airway). A review of Patient 1?s discharge summary from the GACH, dated November 9, 2007 (prior to the patient?s admission), indicated the patient went missing from another skilled nursing facility and became homeless.A nurse?s progress note, dated November 9, 2013, indicated the patient was last seen at 2:30 p.m., on the patio in her wheelchair while smoking a cigarette with other patients. At 4 p.m., the patient was not found in her room, hallway or on the patio. According to the progress note, patient 1 was alert and able to push herself in the wheelchair. The note also indicated facility?s staff searched the surrounding neighborhood, but the patient could not be found. At 5 p.m., the patient?s physician was notified, at 7 p.m., the family was notified, and at 8:50 p.m., Patient 1?s elopement was reported to the Police Department. There was no documented evidence the facility notified the Department of the patient?s elopement.On November 15, 2013 the facility?s staff conducted interviews with other patients who had come in contact with Patient 1 on November 8, 2013. The patients? stated Patient 1 was upset about not having money to buy cigarettes and having to borrow cigarettes. She told another patient she was upset and going to leave the facility because she did not like the idea of having certain smoking hours. One of the patients saw Patient 1 outside of the facility in the parking lot, when asked what she was doing, Patient 1 stated she was looking for cigarette butts.A review of Patient 1?s care plans, dated August 19, 2012, and updated on October 13, 2013, did not address the patients smoking habits. On November 22, 2013 (fourteen days later), at approximately 7 p.m., a family member notified the facility indicating the patient had been found and was at a Police Department, which was approximately 25 miles away from the facility. The Police transported the patient back to the facility and arrangements were made to have the patient evaluated at a GACH.On July 28, 2014, at 1:50 p.m., Employee 1 was interviewed, the employee stated he talked with the patient all the time and she would become very upset and aggressive if she did not get a cigarette. Employee 2 when interviewed, on July 28, 2014, at 3:15 p.m., stated the patient lived in the facility since 2007 and had never eloped before. Employee 2 stated the patient had mood swings,on some days the patient was nice, and on other days she was angry and cursing at everyone. Employee 2 was asked how he thought the patient traveled 25 miles away in a wheelchair. He replied, ?On the bus.? He further stated, the city will allow people in wheel chairs to ride the bus for free. There was a bus stop observed outside of the facility, near the facility?s parking lot.Employee 2 was asked; if he or anyone notified the Department of Patient 1?s elopement and he stated ?No.? He stated he was told if the patient was found they did not need to report the incident.A review of the facility?s policy titled, ?Social Service Policy and Procedure? with a revision date of November 2013 for Elopement /Missing Patient (#18) indicated if the patient is not found within 24 hours, the Department of Health would be notified. The facility?s staff failed to: 1. Report Patient 1?s elopement from the facility within 24 hour as required by State Regulations. 2. Following its policy and procedure of notifying the Department within 24 hours of an elopement or of a missing patient.The above violation, jointly, separately, or in any combination had a direct or immediate relationship to Patient 1?s health, safety and security. |
| 940000037 |
Santa Fe Heights Healthcare Center LLC |
940011470 |
B |
13-May-15 |
V3K111 |
5883 |
1418.21. (a) A skilled nursing facility that has been certified for purposes of Medicare or Medicaid shall post the overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) in accordance with the following requirements:(1) The information shall be posted in at least the following locations in the facility:(A) An area accessible and visible to members of the public.(B) An area used for employee breaks.(C) An area used by residents for communal functions, such as dining, resident council meetings, or activities.(2) The information shall be posted on white or light-colored paper that includes all of the following, in the following order:(A) The full name of the facility, in a clear and easily readable font of at least 28 point.(B) The full address of the facility in a clear and easily readable font of at least 20 point.(C) The most recent overall star rating given by CMS to that facility, except that a facility shall have seven business days from the date when it receives a different rating from CMS to include the updated rating in the posting. The star rating shall be aligned in the center of the page. The star rating shall be expressed as the number that reflects the number of stars given to the facility by CMS. The number shall be in a clear and easily readable font of at least two inches print.(D) Directly below the star symbols shall be the following text in a clear and easily readable font of at least 28 point:"The above number is out of 5 stars."(E) Directly below the text described in subparagraph (D) shall be the following text in a clear and easily readable font of at least 14 point:"This facility is reviewed annually and has been licensed by the State of California and certified by the federal Centers for Medicare and Medicaid Services (CMS). CMS rates facilities that are certified to accept Medicare or Medicaid. CMS gave the above rating to this facility. A detailed explanation of this rating is maintained at this facility and will be made available upon request. This information can also be accessed online at the Nursing Home Compare Internet Web site at http://www.medicare.gov/NHcompare. Like any information, the Five-Star Quality Rating System has strengths and limits. The criteria upon which the rating is determined may not represent all of the aspects of care that may be important to you. You are encouraged to discuss the rating with facility staff. The Five-Star Quality Rating System was created to help consumers, their families, and caregivers compare nursing homes more easily and help identify areas about which you may want to ask questions. Nursing home ratings are assigned based on ratings given to health inspections, staffing, and quality measures. Some areas are assigned a greater weight than other areas. These ratings are combined to calculate the overall rating posted here."(F) Directly below the text described in subparagraph (E), the following text shall appear in a clear and easily readable font of at least 14 point:"State licensing information on skilled nursing facilities is available on the State Department of Public Health's Internet Web site at: www.cdph.ca.gov, under Programs, Licensing and Certification, Health Facilities Consumer Information System."(3) For the purposes of this section, "a detailed explanation of this rating" shall include, but shall not be limited to, a printout of the information explaining the Five-Star Quality Rating System that is available on the CMS Nursing Home Compare Internet Web site. This information shall be maintained at the facility and shall be made available upon request.(4) The requirements of this section shall be in addition to any other posting or inspection report availability requirements.(b) Violation of this section shall constitute a class B violation, as defined in subdivision (e) of Section 1424 and, notwithstanding Section 1290, shall not constitute a crime. Fines from a violation of this section shall be deposited into the State Health Facilities Citation Penalties Account, created pursuant to Section 1417.2.(c) This section shall be operative on January 1, 2011. Based on observation, interview, and record review, the facility failed to post the overall facility star ratings given by the Center of Medicare and Medicaid Services (CMS) to the facility.On 1/15/15 from 8:00 a.m. to 9:00 a.m., during an initial tour of the facility, the evaluator noted that the star ratings information was not posted at the front lobby, the employee lounge, the dining room, or the activities room. On 1/15/15 at 10:50 a.m., during an interview, the administrator stated the star ratings information was supposed to be posted; however, he could not find the posting. The administrator stated the facility should have three or four stars, and he needed to double check with the Director of Nursing (DON). On 1/15/15, at 11:15 a.m., during an interview, the DON stated the facility received a letter from (CMS) indicated the facility overall quality was changed from four stars to three stars. The DON further stated the posting should be posted in the front lobby. On 1/15/15, at 11:25 a.m., during an observation, there was no star ratings information posted at the front lobby. On 1/15/15, the DON provided a copy of an updated print-out of the facility's star ratings report from CMS. The print-out indicated the facility's overall quality star ratings was "three stars".On 1/15/15, at 11:30 a.m., during an interview, the administrator stated, he would have the facility's receptionist make a sign reflecting three stars and post it.The above violation either jointly, separately, or in any combination had a direct or immediate relationship to patient health, safety, or security. |
| 940000037 |
Santa Fe Heights Healthcare Center LLC |
940012049 |
A |
02-Mar-16 |
2NOL11 |
15214 |
F323 ?483.25 (h) The facility must ensure that: (1)The resident environment remains as free from accident hazards as is possible; and (2)Each resident receives adequate supervision and assistance devices to prevent accidents F309 ?483.25 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. F 221 ?483.13(a) The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident?s medical symptoms. The Department received an entity reported incident (ERI) from the facility on 10/10/14, alleging that on 10/9/14, a resident (Resident 1) was discovered in bed with his head through the side rail and the body off the bed. The resident was unresponsive without any respirations or pulse, and was pronounced deceased by the paramedics. The facility failed to ensure that the resident?s environment remains as free from accident hazards as possible, and each resident receives adequate supervision and assistance devices to prevent accidents; to provide Resident 1 with the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with comprehensive assessment and plan of care; and to ensure that each resident is free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident?s medical symptoms, including but not limited to: 1. Failure to follow standard hospital bed safety procedures and U.S. Food and Drug Administration (FDA) guidance and recommendations for bed side rails dimension to prevent body entrapment. 2. Failure to follow the facility?s policy in using less restrictive measures, prior to using side rail restraints. 3. Failure to closely monitor Resident 1, who was identified to be restless, agitated, and was making many attempts to get up out of the bed, frequently as indicated in the resident?s plan of care policy. As a result of the facility?s failures Resident 1 was found unresponsive, with no pulse and not breathing with his head entrapped and protruding through the side rail?s large middle space, while his body was hanging off the bed onto the floor. Resident 1 was pronounced deceased by the paramedics on 10/9/14 at 8:10 p.m.On 10/17/14, an unannounced visit to the facility was made to investigate the ERI.On 10/17/14, at 10 a.m., during an interview, the director of nursing (DON) stated that Resident 1 was at the facility for only three days. The DON stated Resident 1 was being observed as a new admission for 72 hours and was to be observed by the staff once per shift. The DON stated Resident 1 would scream all the time, but could not make his needs known.On 10/17/14, at 11:15 a.m., Resident 1?s bed was observed with the director of nurses (DON). When the entrapment occurred, the bed?s side rails measured 7 ¬ inches wide by 7 « inches. All the residents? beds in the facility were checked and there were two beds observed with similar large opened side rail spacing The DON stated the spacing was large enough for a resident?s head to fit in between the rails.A review of a FDA Guidance for Industry and FDA Staff, titled, ?Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated August 30, 2004, indicated the following dimensional limits for side rails: Within the rail<120mm (<4 ? inch) Under the rail<120mm (<4 ? inch) Between rail/mattress<120mm (<4 ? inch)Resident 1?s bed rails opening dimensions were much larger than the above dimensional limits, measuring at 7 ¬ by 7 « inches. On 10/17/14, at 11:30 a.m., during a concurrent observation and interview, the administrator stated, ?The bed rails should not have openings that are larger than 120 mm (4.72 inches).? On 10/21/14, at 2 p.m., the administrator stated he had received a CMS (Centers for Medicare and Medicaid Services) AFL (all facilities letter) indicating that the maximum opening of residents? beds side rails should be 120 millimeters ([mm], which is equal to 4.7 inches). The administrator was asked to see the letter, but he stated the letter was received ?several years ago," and he was not able to locate the letter.
On 10/21/14, at 2:30 p.m., a certified nursing assistant (CNA1) was interviewed. CNA 1 stated she was the one who found Resident 1 with his head through the rail and body hanging off the bed on 10/9/14. CNA 1 stated she was not assigned to care for Resident 1, but was passing nourishment to the residents and saw Resident 1. CNA 1 stated Resident 1 was found in bed, with his head through the center space on the upper side rail on the right side of the bed. CNA 1 stated the resident was lying on his right side with his body and legs hanging off the side of the bed and the resident?s back was to the door. CNA 1 stated Resident 1 was pale and had no respirations (not breathing). She called for the nurse to come and assist and 911 was also called. CNA 1 stated she could not recall the time the incident occurred, but stated it was after 7 p.m.
At 2:55 p.m., on 10/21/14, CNA 2 was interviewed. CNA 2 stated he was the assigned care giver for Resident 1 on 10/9/14 for the p.m. shift (3 p.m.-11 p.m.). CNA 2 stated he had provided care to Resident 1 at 6:45 p.m., and was relieving other CNAs at 7 p.m., but had his lunch at 7:30 p.m. CNA 2 stated he was called to Resident 1's room and he saw Resident 1 on the floor and CPR (cardiopulmonary resuscitation) had been initiated. When CNA 2 was asked about Resident 1?s bed?s side rails, he stated Resident 1 used the « side rails, but CNA 2 stated he did not notice the size of the openings between the rails. CNA2 stated Resident 1 was normally alert with periods of disorientation and confusion and would move around in the bed a lot.
However, a review of the paramedics? EMS (emergency medical services) Report, dated 10/9/14, and timed as being summoned at 2005 hour (at 8:05 p.m.). The EMS Report indicated Resident 1 was seen on the floor with CPR being given and was ?DOA? (dead on arrival). The report indicated Resident 1 was last seen at ?6 p.m.? by the staff, which is contrary to CNA 2?s interview of providing care to Resident 1 at 6:45 p.m. According to the paramedics? report, Resident 1 had ?rigor mortis (after death, blood collects in parts of the body resulting in stiffness) to the mandible (jaw) and extremities.?
A review of Medscape, an online medical reference site, indicated rigor mortis begins within one-two hours after death.
On 10/21/14, during an interview, at 3:30 p.m., a licensed vocational nurse (LVN 1) stated she administered medications to Resident 1 on 10/9/14 at 5 p.m., and Resident 1 was quiet at that time. LVN 1 stated she was called to the room when a CNA called for assistance, but LVN 1 could not recall who found the resident, nor the time of the call. LVN 1 stated she was in the nurses? station, directly across from Resident 1's room. She stated the resident was in the bed, with his head through the space in between the side rail and the head of the bed was elevated at 45 degrees, because the resident was receiving G-tube feeding ([gastric feeding] nutrition delivered through a plastic tube inserted through the abdominal wall directly into the stomach). LVN 1 stated Resident 1 was removed from the bed, placed on the floor, CPR was initiated, and 911 emergency services were called. LVN 1 stated Resident 1 was without respirations (breathing) or a pulse (heart beat) but was warm to the touch.
A review of the facility?s Incident Report, dated 10/9/14, indicated Resident 1's death occurred at 7:55 p.m. However, according to the paramedic?s EMS report, they were not summoned to the facility, until 8:05 p.m. The report indicated the resident was found in bed with his head in the middle section of the bed?s right side rail and the resident?s body was half way to the floor. The report indicated the resident had no pulse or respiration and CPR was initiated. The incident report included interviews from five staff members.
The facility provided a written bed list with side rail?s measurement included. Two beds were identified as having large spacing of the side rails.
A review of Resident 1?s Admission Face Sheet indicated the resident was a 70 year-old male who was newly admitted to the facility on 10/6/14 at 6 p.m. Resident 1?s diagnoses included dysphagia (difficulty in swallowing), Parkinson's disease (a degenerative disorder of the central nervous system mainly affecting the motor system), psychosis (an abnormal condition of the mind described as involving a loss of contact with reality), schizophrenia (a mental disorder often characterized by abnormal social behavior and failure to recognize what is real) and anxiety.
A review of Resident 1?s admission orders, dated 10/6/14, and timed at 9 p.m., indicated the resident was prescribed to receive the following mood-altering medications via GT-tube: Seroquel (anti-psychotic) 200 mg every night and twice a day (BID) for schizophrenia; and Haldol (anti-psychotic) 5 mg every 6 hours PRN (whenever necessary) for agitation; and Lorazepam (anti-anxiety) one mg every eight hours for restlessness and anxiety. The physician?s order also indicated bilateral side rails for Resident 1 to be used as an enabler for safety and repositioning and place the resident on fall precautions.
A review of a ?Physical Restraint Review form, dated 10/6/14, indicated the triggers for Resident 1?s restraints use were the following:
Resident 1 was unable to follow directions; had poor safety awareness; and poor sitting balance, with an aggressive/disruptive behavior. Under side rails; ?¬ bilateral side rails? was written.
A review of an undated Fall Risk Evaluation indicated Resident 1 had a score of 13. The document indicated that a score greater than 10 indicated the resident was a high risk for falls.
A Physical Restraint Review form, dated 10/06/14, indicated Resident 1 was unable to follow directions, had poor safety awareness, poor balance, with aggressive and/or disruptive behaviors. The document indicated the resident was to have a ¬ bilateral (both sides) bed side rails. An entry, dated 10/7/14, indicated Resident 1 "moved around in his bed constantly and removed the pillows used to position the resident.?Resident 1?s first 72 hours of admission nursing documented entries indicated on 10/7/14, at 7 a.m., Resident 1 was constantly trying to get out of the bed with the following data entries:1. On 10/7/14, at 9 p.m., Resident 1 had episodes of yelling and being restless. 2. On 10/8/14, at 6 a.m., Resident 1 had episodes of yelling and restlessness.3. On 10/9/14, at 3 p.m. and 7 p.m., Resident 1 had episodes of confusion. 4. On 10/9/14, at 7:35 p.m., Resident 1 was in bed, yelling and the pillows and blankets used for positioning the resident were found on the floor.5. On 10/9/14, at 7:55 p.m., Resident 1 was found in bed, with his head through the rail, pulseless and without respirations. A care plan, dated 10/6/14, and titled, ?Both ¬ Side Rails,? indicated Resident 1 was to have ¬ side rails up on each side of the bed. The resident?s goal was to be free from accident or incidents of a fall or injury. The staff?s approach included maintenance checks of the equipment as needed and to continue to evaluate the effectiveness of the side rails as needed.Another care plan, dated 10/6/14, and updated on10/7/14, titled, ?Risk for injury,? indicated the staff?s plan of approach included to assess the restraint complications and intervene accordingly; place a small pillow on the right side of the side rail; constant reminders of the importance of the pillow placement as padding for the side rail to prevent injuries and the CNAs to keep the pillow against the side rail.A review of an Interdisciplinary Team (IDT) Conference Record, dated 10/8/14, indicated Resident 1 was a newly admitted resident who had episodes of screaming, bending down in his wheelchair, and sitting on the edge of the bed, and was to be closely monitored for fall risks.A review of a Psycho-social Assessment Form, dated 10/6/14, indicated Resident 1 was confused at times and had episodes of restlessness.A review of the facility?s policy, dated 8/2005, and titled, ?Clinical Nursing Services Policy and Procedure/Side Rails,? indicated side rails will only be used on residents whose movement should be restricted due to safety, but only after the facility had attempted to use less restrictive alternatives. The policy indicated a restraint assessment should be done with the approval of the IDT team. The policy also stipulated that less restrictive measures that were attempted should be documented.A review of an online Public Health Notification/FDA Safety Alert: titled, ?Entrapment Hazards,? dated 8/23/1995, indicated that entrapment occurs through the bars of side rails, and deaths occurred with entrapment of the head, neck or thorax. The document indicated that bed side rails should have no gap wide enough to entrap a patients head or body. The document indicated additional safety measures should be considered for residents who had been identified as having high risk for entrapment, such as residents with altered mental status and general restlessness, all of which were attributes and behaviors of Resident 1.A review of Resident 1?s death certificate indicated the resident?s cause of death was: 1. Sequelae of cerebral vascular accident (after effect of a CVA). 2. Arteriosclerotic vascular disease (disease of the heart).The facility failed to ensure that the resident?s environment remains as free from accident hazards as possible, and each resident receives adequate supervision and assistance devices to prevent accidents; to provide Resident 1 with the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with comprehensive assessment and plan of care; and to ensure that each resident is free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident?s medical symptoms, including but not limited to:1. Failure to follow standard hospital bed safety procedures and U.S. Food and drug Administration (FDA) guidance and recommendations for bed side rails dimension to prevent body entrapment.2. Failure to follow the facility?s policy in using less restrictive measures, prior to using side rail restraints.3. Failure to closely monitor Resident 1, who was identified to be restless, agitated, and was making many attempts to get up out of the bed, frequently as indicated in the resident?s plan of care policy.The above violations, jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would |
| 940000037 |
Santa Fe Heights Healthcare Center LLC |
940012755 |
A |
16-Nov-16 |
V8CM11 |
19992 |
F223 ? 42 CFR 483.13(b). Abuse. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. F323 - 42 CFR 483.25(h) (2). Accidents and Supervision. The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. F501 ? 42 CFR 483.75(i) Medical Director. (1) The facility must designate a physician to serve as medical director. (2) The medical director is responsible for: (i) implementation of resident care policies; and (ii) the coordination of medical care in the facility. On 11/25/14, at 2 PM, an unannounced visit to the facility was made to investigate an entity reported incident regarding an allegation that Resident 2 sexually abused Resident 1. Based on observation, interview and record review, the facility failed to adequately supervise Resident 2 and protect Resident 1 from sexual abuse by failing to: 1. Conduct a wandering risk assessment and develop a care plan at admission to address Resident 2?s history of wandering inside female residents rooms and touching a female resident. 2. Establish measures to monitor Resident 2?s activity and whereabouts to prevent Resident1?s wandering inside other residents' rooms. 3. Identify that the hourly monitoring ordered by Resident 2?s attending physician would not keep Resident 1 safe and manage the behavior of Resident 2, who was going inside Resident 1?s room at least every fifteen minutes. 4. Coordinate Resident 2?s care with the medical director to provide further guidance and oversight of care when the hourly monitoring ordered by the attending physician was not appropriate to manage Resident 2?s behavior. These deficient practices resulted in Resident 2 sexually assaulting Resident 1, which led Resident 1 to have increasing screaming episodes in the facility, daily use of an anti-anxiety medication (Ativan), and a transfer to an acute care hospital for an evaluation. A review of Resident 2's medical record indicated that the resident was initially admitted to the facility on 10/29/14 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), depression, and schizophrenia (a severe psychiatric disorder with symptoms of emotional instability, detachment from reality, and withdrawal into the self). The Change in Condition Assessment, dated 11/3/14, indicated Resident 2 was seen inside a female resident's room (Resident 3) and was attempting to touch Resident 3?s back. Resident 2 stated he wanted to hug Resident 3. According to the Mental and Behavioral Health Treatment Progress Note, dated 11/3/14, a licensed psychologist evaluated Resident 2 due to the report from the facility staff that Resident 2 was going inside the room of a female resident (Resident 3). The psychologist progress note indicated that according to Resident 2, he wanted to say ?Hi? and be friendly to Resident 3. The psychologist progress note indicated there was no reported sexual activity; Resident 2 was instructed that he could not visit any resident?s rooms; and Resident 2 stated he understood and he had never been in a skilled nursing facility before. The psychologist progress note indicated Resident 2 needed to be observed closely to make sure he stayed within agreed limits. A review of the Licensed Personnel Weekly Progress Notes, dated 11/4/14, at 2 PM, indicated that Resident 2 required monitoring secondary to the behavior of "visiting females (residents) rooms." A review of the Resident Transfer and Referral Record, dated 11/5/14, indicated Resident 2 was transferred to a general acute care hospital (GACH) due to increased confusion and sexually inappropriate behavior. According to Resident 2's medical record, the resident was re-admitted on 11/10/14 at 1 PM. The Nursing Admission Assessment, dated 11/10/14, indicated the resident used a wheelchair to go around the facility. A review of the Interdisciplinary Conference Record, the care plan, and the Change of Condition Assessment, dated 11/11/14, indicated Resident 2 inappropriately pulled the activity assistant's pants' eyelet (the part of the pants where you put the belt through). A review of the social services designee (SSD) notes indicated Resident 2 grabbed the back of the smoking monitor (the activity assistant) pants, pulling down the pants to where she was exposed in the back. When asked why he pulled the smoking monitor?s pants, Resident 2 stated that he was trying to get her attention to get a cigarette. Resident 2 was made aware that his behavior would not be tolerated at this facility and the resident stated he understood. The resident was sent out (to the hospital) for psychiatric evaluation. A Physician?s order, dated 11/11/14, indicated to transfer Resident 2 to an acute care facility for increased confusion and aggressive sexual behaviors. According to the GACH?s Psychiatric Diagnostic Evaluation, dated 11/12/14, Resident 2 was admitted to the psychiatric unit on 11/11/14 and was diagnosed to have possible major depressive disorder, recurrent type. Resident 2 was seen in the emergency room from the facility due to the resident getting increasingly depressed, increasingly agitated, increasingly aggressive behavior, and touching staff inappropriately. This was the resident?s first psychiatric hospitalization and he has not been on psychiatric medications. The GACH?s discharge summary, dated 11/17/14, indicated Resident 2 was continued on closed observation and he had displayed sexually inappropriate behavior and was counseled about this behavior. The resident was sent back to the skilled nursing facility. According to Resident 2's medical record, the resident was re-admitted on 11/17/14, his third admission to the facility. A review of the Admission Orders, dated 11/17/14, indicated the following orders for Resident 2: 1. The resident may be up in a wheelchair daily as tolerated. 2. Administer Restoril 15 milligrams (mg) QHS (at bedtime) by mouth for insomnia/inability to sleep. 3. Administer Depakote 250 mg QHS by mouth for schizophrenia manifested by inappropriate touching of female staff. 4. Administer Ativan 2 mg every four (4) hours as needed by mouth for anxiety manifested by inability to rest. There was no documented evidence in the clinical record that the facility conducted an assessment and developed a plan of care at admission to address Resident 2?s history and risk of wandering inside female residents? rooms and his behavior of touching a female resident. A review of the Licensed Personnel Admit and First 72 Hours Notes, dated 11/18/14 at 7:10 AM, indicated Resident 2 was able to reposition self, needed supervision when transferring from and to the wheelchair, and was able to propel his wheelchair independently. The Licensed Personnel Admit and First 72 Hours Notes, dated 11/23/14, indicated the following: 1. At 4:30 PM, a certified nursing assistant (CNA) reported to the charge nurse that Resident 2 was seen wandering in and out of other residents' rooms. The licensed nurse documented Resident 2 was educated about the facility's rules and was given Ativan for inability to relax. 2. At 5 PM, Resident 2 was observed in the room of Resident 1, and was "showing behaviors of inappropriately touching" Resident 1. The licensed nurse educated Resident 2 about the facility's rules and sexual harassment, and explained to Resident 2 that if he continued the inappropriate behavior, the licensed nurse would call the police. Resident 2 informed the licensed nurse that he would go inside his room and sleep. The licensed nurse documented "Will continue to monitor." The 5 PM wandering episode was described instead by a certified nursing assistant (CNA 1) as occurring after dinner at about 6 PM. According to the facility's written statement record, dated 11/24/14, CNA 1 stated that on 11/23/14 after dinner at about 6 PM, she heard yelling (not consistent with usual yelling) coming from Resident 1's room while she (CNA 1) was in another resident's room. CNA 1 stated that she went to Resident 1's room and found Resident 2 in bed with Resident 1, trying to climb on top of Resident 1. Upon knowledge of CNA 1's presence, Resident 2 jumped out of Resident 1's bed and into his wheelchair and went out of Resident 1's room and down the hallway fast. CNA 1 stated a licensed vocational nurse (LVN 1) told Resident 2 to stay out of women's rooms. CNA 1 stated that about fifteen minutes later (this was the second incident), the housekeeper (HSKPR 1) told the facility staff to keep an eye on Resident 2 because he goes into rooms and takes things out. CNA 1 stated that HSKPR 1 found Resident 2 in bed with Resident 1 "again," and Resident 2 "was in bed lying next to Resident 1 by her shoulder." About 20 minutes later after the second incident, CNA 1 found Resident 2 in Resident 1's bed again, trying to climb on top of Resident 1. A review of the physician order, dated 11/23/14 at 8 PM, indicated to start hourly wandering/elopement monitoring for 72 hours on Resident 2. The Hourly Wandering/Elopement Monitor sheet indicated Resident 2 was in his room at 8 PM, 9 PM, 10 PM, and 11 PM. The licensed nurse implemented the hourly monitoring ordered by Resident 2?s attending physician without identifying that this order would not appropriately manage Resident 2?s behavior of entering Resident 1?s room at least every 15 minutes. There was no documented evidence the licensed nurse discussed with the attending physician the appropriateness of the hourly monitoring order. There was no documented evidence the licensed nurse involved the medical director to coordinate an appropriate approach for Resident 2 and to provide guidance to manage Resident 2?s behavior, if the licensed nurse disagreed with the attending physician?s order or had difficulty in contacting or communicating with the attending physician. The Licensed Personnel Admit and First 72 Hours Notes, dated 11/23/14 at 11:08 PM, indicated Resident 2 was observed in the Nursing Station A and B, propelling his wheelchair independently. The facility's written statement record, dated 11/24/14, indicated that at around 11:20 PM on 11/23/14, CNA 2 found Resident 2 in Resident 1's room again. CNA 2 saw Resident 1's curtain was pulled around the bed and went inside Resident 1's room to investigate and found Resident 2 with his right hand in Resident 1's vagina. CNA 2 called CNA 1 into Resident 1's room. CNA 1saw the diaper of Resident 1 was torn off this time. Both CNAs removed Resident 2 from the room and reported to LVN 2 (the night shift charge nurse) that Resident 2 was "messing? with Resident 1. The Licensed Personnel Admit and First 72 Hours Notes, dated 11/24/14 and timed at 7:30 AM, indicated Resident 2 was observed roaming around the facility. A review of the Change in Condition Assessment for Resident 1 indicated that on 11/24/14 at 7:30 AM, the resident had episodes of screaming, was restless, and was administered Ativan via the gastrostomy tube. The day shift (7 AM to 3 PM shift) licensed nurse documented that a report was received from the night shift nurse that there was a suspected sexual abuse/inappropriate touching of Resident 1 by a male resident. At 9 AM, the licensed nurse informed the hospice agency about the incident. The hospice physician ordered to transfer Resident 1 to an acute care hospital for further evaluation/clearance related to suspected sexual abuse. At 10 AM, Resident 1 was transferred to the acute care hospital. At 5:15 PM, Resident 1 returned to the facility. On 11/25/14 at 4 PM, during an observation, Resident 1 was lying in her bed. Resident 1 was asked about the incident, but the resident did not give a response to any verbal inquiries. The resident smiled when her name was spoken, and followed movement with her eyes, but she did not give verbal responses. On 11/25/14, at 2 PM, the administrator (ADM) was interviewed. The ADM stated that Resident 1 was sent to an acute care hospital on 11/24/14, following the incidents on 11/23/14 and 11/24/14 for an evaluation. The ADM stated that Resident 1 had increased incidents of yelling since her return from the hospital, and was given medication for apparent increased anxiety. During this interview, the ADM stated that Resident 2 was sent out from the facility for psychological evaluation on 11/24/14. The Licensed Personnel Admit and First 72 Hours Notes indicated Resident 2 left the facility at 1:45 PM. On 11/25/14, at 3:40 PM, during an interview, the evening shift (3 PM - 11 PM) charge nurse (LVN 1) on duty on 11/23/14, stated that Resident 2 had a history of wandering. On 12/9/14, at 2:30 PM, Resident 2's medical record was reviewed with the director of nursing (DON 1). DON 1 stated, during an interview, she was not aware of Resident 2's behavior of wandering until after the incidents on 11/23/14. During the interview, DON 1 was not able to locate any care plans addressing the wandering or inappropriate sexual behaviors of Resident 2. DON 1 stated that those behaviors should have had care plans to protect other residents in the facility. On 12/10/14, at 6:35 AM, during an interview, CNA 2, the night shift (11 PM to 7 PM) CNA, stated at approximately 11:30 PM, CNA 2 observed the room of Resident 1 with the privacy curtains pulled around the bed, and CNA 2 stated that this was unusual. CNA 2 stated that when she looked behind the curtains, she observed that Resident 2 was on his wheelchair next to Resident 1's bed, Resident 1's diaper was pulled away and Resident 2's hand was in the groin area of Resident 1. On 7/20/16 at 5:26 p.m., during an interview, DON 2 stated she was employed by the facility on June 2016. The facility?s admission process was discussed with DON 2 and she stated that prior to re-admitting a resident with a new psychiatric diagnosis, the facility would ask the GACH?s behavioral unit to send a copy of the psychiatric evaluation for her review, and the clearance from the clinical (medical) and behavioral unit. DON 2 stated Resident 2 was cleared by the GACH?s behavioral unit for discharge back to the facility prior to his readmission on 11/17/14. During the interview, Resident 2?s wandering behavior in Resident 1?s room was discussed with DON 2. DON 2 stated a new behavior, such as wandering, is a change of condition and the licensed nurse should notify the attending physician within an hour after completing an SBAR (Situation, Background, Assessment, and Recommendation ? a tool to share patient information in a clear, complete, concise and structured format; improving communication efficiency and accuracy). During the interview, DON 2 stated that if Resident 2?s wandering behavior was becoming frequent, the resident should have been placed on a one-to-one monitoring (one staff assigned to monitor a resident?s activities). DON 2 stated a nurse could not monitor the resident every hour because they were providing care to other residents and an hourly monitoring was not an attainable goal. DON 2 stated if the licensed nurse felt the attending physician?s order was not appropriate, she expected the licensed nurse to speak with the attending physician and discuss how the order would not work. On 7/20/16 at 6:30 p.m., during an interview, the medical director stated he has been the medical director of the facility for a year now and he was made aware of the incident between Resident 1 and 2. When asked what would he be ordering if Resident 2?s wandering behavior persisted and he was having a change of condition, the medical director stated he would order routine laboratory tests to rule out confusion, a one-on-one sitter to watch the resident, a psychiatric evaluation, and a follow-up with the resident?s family. The medical director stated that if the resident?s laboratory tests were abnormal, he would order to transfer the resident to the hospital. During the interview, the medical director stated he encouraged the licensed nurses, based on their nursing scope of practice, to question or discuss an attending physician?s order if the licensed nurse did not agree with the order. The medical director stated that if the attending physician was not persistent or not calling the nurse back, the nurse should call him. According to the Medical Director Agreement, the medical director is responsible for overall coordination of the medical care in the facility including ??C. Periodic evaluation of the adequacy and appropriateness of professional health care and supportive staff and services?E. ?Emergency back-up coverage? if the regular attending physician is unavailable.? A review of Resident 1's medical record indicated that the resident was admitted to the facility on 10/9/13, with diagnosis that included dysphagia (the inability to swallow), status post tube insertion (gastrostomy tube or G-tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications), and anxiety. The resident was placed on hospice care (a type and philosophy of care that focuses on the palliative care of a terminally ill or seriously ill patient's pain and symptoms, and attending to their emotional and spiritual needs) on 1/28/14. A review of a Minimum Data Sheet (MDS, an assessment and care planning tool), dated 5/30/14, indicated that Resident 1 had unclear speech, rarely/never made herself understood, rarely/never understood others, was severely impaired in cognitive skills for daily decision-making, and was totally dependent on staff for all activities of daily living. The Physicians Orders for November 2014 indicated that Resident 1 had an order for Ativan, one (1) mg sublingual (under the tongue) every 6 hours, as needed, for agitation or restlessness since written on 7/22/14. On 11/23/14, the Ativan order was changed to one (1) mg tablet, via G-Tube every 6 hours as needed for anxiety or agitation. A review of Resident 1's Medication Administration Record (MAR) for November 2014 indicated Resident 1 received Ativan nine times from November 1 to November 22 (for 22 days). After the alleged sexual abuse on 11/23/14, the MAR indicated Resident 1 received Ativan 7 times from November 23 to November 30 (for eight days). According to the social service progress notes, dated 11/26/14, Resident 1 was visited by a forensic nursing specialist, who conducted a sexual assault exam. A review of Resident 3's clinical record indicated the resident was admitted to the facility on1/9/12 with diagnoses that included dementia, legal blindness, and anxiety disorder. The facility failed to adequately supervise Resident 2 and protect Resident 1 from sexual abuse by failing to: 1. Conduct a wandering risk assessment and develop a care plan at admission to address Resident 2?s history of wandering inside female residents rooms and touching a female resident. 2. Establish measures to monitor Resident 2?s activity and whereabouts to prevent Resident1?s wandering inside other residents' rooms. 3. Identify that the hourly monitoring ordered by Resident 2?s attending physician would not keep Resident 1 safe and manage the behavior of Resident 2, who was going inside Resident 1?s room at least every fifteen minutes. 4. Coordinate Resident 2?s care with the medical director to provide further guidance and oversight of care when the hourly monitoring ordered by the attending physician was not appropriate to manage Resident 2?s behavior. 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. |
| 940000037 |
Santa Fe Heights Healthcare Center LLC |
940012877 |
B |
10-Jan-17 |
KW5W11 |
6069 |
483.12(b) F205 Notice of Bed-Hold Policy and Readmission 483.12(b)(1) 483.12(b)(2) Based on interview and record review, the facility failed to follow its bed-hold policy and failed to re-admit one of one resident (Resident 1). Resident 1 was transferred to a general acute care hospital (GACH) on 4/23/16, and the facility failed to permit Resident 1 to return and resume residence in the facility during the bed-hold period. This deficient practice resulted in Resident 1 being transferred to another skilled nursing facility (SNF 2) without proper preparation and notice and subjected Resident 1 to undue stress and anxiety. Findings: On 7/7/16, at 7:30 a.m., an unannounced complaint investigation was conducted to investigate the facility's refusal to re-admit Resident 1 from the GACH. A review of Resident 1's Admission Face Sheet indicated Resident 1 was admitted to the facility on XXXXXXX Resident 1's admitting diagnoses included end stage renal disease, dependence on renal dialysis (a process for removing waste and excess water from the blood and is used primarily as an artificial replacement for lost kidney function in people with kidney failure), hypertension (also known as high blood pressure, a long term medical condition in which the blood pressure in the arteries is persistently elevated), and type 2 diabetes mellitus (a long term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). A review of Resident 1's Minimum Data Set (MDS/a standardized assessment and care screening tool) dated 4/21/16, indicated the resident had impaired cognition with memory problem. The Licensed personnel progress notes from 4/15/16 to 4/21/16 indicated the resident was alert and verbally responsive with periods of screaming, yelling and being verbally abusive to staff. On 7/7/16, at 10:17 a.m., during an interview, the Director of Nursing (DON) stated that according to the medical record, Resident 1 was transferred to GACH on XXXXXXX for further evaluation and dialysis. The DON stated that she did not have any knowledge as to the reason for not re-admitting Resident 1 because she was not the DON at that time. On 7/7/16, at 10:37 a.m., during an interview, the Admission Coordinator (AC 1) stated he was not aware of any reason for not re-admitting Resident 1. AC 1 stated AC 2 had no documentation regarding the reason for not re-admitting Resident 1. On 7/7/16, at 11:00 a.m., during an interview, the Administrator (ADM) stated that in all re-admissions, he is always consulted but in the case of Resident 1, he does not remember if he was consulted. The ADM stated that they have been refusing several or two re-admissions because of the inability of the facility to provide care but was not sure if Resident 1 was one of those residents. On 7/7/16, at 1:45 p.m., during a record review with the Director of Nursing (DON), the situation, background, assessment and recommendation (SBAR) and interdisciplinary team (IDT) notes indicated that Resident 1 had been refusing hemodialysis on several occasions. On 7/7/16, at 2:00 p.m., during an interview, the DON stated that if a resident is refusing hemodialysis, facility staff should explain the risk and outcome of refusing hemodialysis. She also stated that if a resident continue to refuse hemodialysis, facility staff will have to notify the primary physician and the resident's responsible party. The DON added that the facility will not refuse to re-admit if a resident is non-complaint with treatment. Further review of Resident 1's licensed progress notes dated 4/23/16, indicated the resident was transferred to the GACH on 4/23/16 per physician's order, for further evaluation and hemodialysis. A review of Resident 1's GACH emergency department (ER) report, dated 4/23/16, at 8:55 p.m., indicated Resident 1 presented to ER via ambulance for evaluation. The ER disposition and plan was to place Resident 1 in telemetry for observation and dialysis. A review of Resident 1's GACH clinical record dated 4/24/16 at 3:06 p.m., indicated Resident 1 was admitted to the hospital for further evaluation, treatment and initiation of hemodialysis. A review of Resident 1's GACH physician's progress notes dated 4/28/16, at 9:09 a.m., indicated Resident 1 was on discharge planning. A review of the documentation of the GACH's Case Manager (CM 1) dated 4/28/16 at 4:30 p.m., indicated that CM 1 informed AC 2 about the anticipated discharge of Resident 1 to the skilled nursing facility (SNF 1). CM 1 notes also indicated that AC 2 refused to take Resident 1 back to SNF 1 because Resident 1 is not cooperating with out-patient hemodialysis. CM 1's further documentation dated 4/29/16 at 1:00 p.m., indicated she spoke with ADM and informed him about the bed hold and that Resident 1 has the right to go back to the facility. She further documented that the ADM stated they could not take Resident 1 back because she is refusing to go to dialysis. A review of Resident 1's GACH clinical record, documented by CM 2, dated 5/4/16 at 3:34 p.m., indicated that Resident 1 was transferred to SNF 2. A review of facility policy and procedure titled "Bed Hold Policy," undated indicated that upon admission of the resident to the facility and upon transfer of the resident from skilled nursing facility to the acute care hospital, the skilled nursing facility shall inform the resident and/ or the resident ' s representative, in writing of the right to exercise the bed hold policy. The skilled nursing facility shall afford the resident a bed hold of seven days, which may be exercised by the resident or the resident's representative. Failure of the facility to follow its policy on bed hold and to permit Resident 1 to return and resume residence in the facility during the bed hold period subjected Resident 1 to undue stress and anxiety. This failure had a direct or immediate relationship to the health, safety and security of Resident 1. |
| 940000037 |
Santa Fe Heights Healthcare Center LLC |
940013379 |
A |
27-Jul-17 |
C2UH11 |
15956 |
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-
(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
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.
Based on interview and record review, the facility failed to provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being and to ensure that residents receive treatment and care, in accordance with professional standards of practice, the plan of care, and resident?s choices; and to immediately inform and consult with Resident 1's physician, when the resident refused treatment; including but not limited to, failures to:
1. Identify the irregularities in Resident 1?s blood sugar levels and notify the director of nursing (DON) and attending physician of these irregularities.
2. Intervene and treat Resident 1?s abnormal high blood sugar levels.
3. Notify Resident 1?s attending physician that the resident refused laboratory (blood) tests, blood sugar level checks, and medications (insulin and Starlix) to manage diabetes mellitus (a chronic condition that prevents the body from getting glucose or sugar from the blood into the body's cells to use as energy, causing weight loss).
4. Conduct an interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident), with the involvement of Resident 1?s physician to address Resident 1's refusal of treatment and to develop appropriate interventions.
5. Review and revise the care plan to manage effectively Resident 1?s continued non-compliance with the treatment (laboratory or blood tests, blood sugar level checks, and medications).
Resident 1, who had a mental illness and type 2 diabetes mellitus, had a behavior of refusing treatment (laboratory blood levels, blood sugar checks, and antidiabetic medications). The resident had a blood sugar level of 400 mg/dL (milligrams per deciliter) twenty-three times between 1/18/17 and 2/15/17 and the facility did not identify the irregularities; therefore, no interventions and treatment was provided to Resident 1, which included notifying the attending physician. The physician was not notified that Resident 1 refused or was non-compliant with the laboratory blood tests, blood sugar level tests, and taking the medications, insulin and Starlix, to manage diabetes mellitus. The facility did not conduct an IDT with the involvement of the physician and did not revise the care plan to address Resident 1?s non-compliance.
These deficient practices resulted in Resident 1's diabetes mellitus remaining untreated. The resident died on XXXXXXX17 after a stay of 30 days at the facility (from XXXXXXX17 to XXXXXXX7) and diabetes mellitus was a significant condition that contributed to Resident 1?s death.
A review of Resident 1?s History and Physical (H&P) from a general acute care hospital (GACH), dated 1/5/17, indicated Resident 1 transferred to the medicine unit of the hospital with the diagnosis of hyperosmotic non-ketotic acidosis (when blood sugar levels rise causing severe dehydration and can lead to seizures, coma, and eventually death). The H&P indicated Resident 1 had a past medical history of noncompliance with medications and treatment, and refusal of care.
A review of Resident 1's Face Sheet (admission record) indicated that the resident was a 48-year-old female, who was admitted to the facility on XXXXXXX17 at 9 p.m. with diagnoses that included but not limited to type 2 diabetes mellitus and schizophrenia (a mental disorder). Resident 1?s admission weight was 121 pounds (lbs). Resident 1 had a conservator (a guardian appointed by the court).
A review of Resident 1's Minimum Data Set (MDS, a resident and care screening tool), dated 2/27/17 indicated the resident?s cognition (ability to reason and think) was intact; the resident exhibited the behavior of rejecting care one to three days within seven days; and she required supervision and set up help for eating.
a. The facility failed to notify Resident 1?s attending physician that the resident refused laboratory tests.
A review of Resident 1's physician order, dated 1/18/17, indicated to obtain from the resident a complete blood count ([CBC], laboratory or lab results that gives information on the number of blood cells and it used to check for conditions), and comprehensive metabolic panel ([CMP], lab results that give information about the current status of certain body organs and acid/base balance). The order indicated lipids (lab results that detect fat levels in blood), and hemoglobin A1c ([HbA1c], a lab result that tells you your average level of blood sugar over the pass 2 to 3 months) every three months.
A review of Resident 1's Diagnostic Laboratories Sheet indicated the resident refused to have blood drawn. The lab sheet indicated the following refusal dates: 1/18/17, 1/19/17, and 1/20/17.
On 3/13/17 at 4p.m., during an interview and concurrent record review of Resident 1's medical record, a registered nurse (RN 1) stated there were no lab results for the resident. RN 1 stated there was no documentation that the physician was notified and made aware that the resident refused lab draws three times. RN 1 stated the physician should have been notified that Resident 1 refused lab draws three times.
On 4/18/17 at 12:15 p.m., during an interview, the DON stated labs are obtained on admission so that there would be baseline labs results of the resident and that interventions are provided as needed based on the lab results.
b. The facility failed to identify the irregularities in Resident 1?s blood sugar levels and notify the DON and attending physician of these irregularities.
A review of Resident 1?s Medication Administration Record (MAR) indicated an order for fingerstick blood sugar monitoring before meals (AC) and before bedtime (QHS) and to administer Novolog, a regular insulin (a fast-acting form of the hormone insulin. It works by helping your body to use sugar properly. This lowers the amount of glucose in the blood, which helps to treat diabetes) sliding scale coverage as to follows:
For blood sugar of 150-199 mg/dL = give 1 unit of insulin subcutaneously (under skin)
For blood sugar of 200-249 mg/dL = give 2 units of insulin
For blood sugar of 250-299 mg/dL = give 3 units of insulin
For blood sugar of 300-349 mg/dL = give 4 units of insulin
For blood sugar of 350-400 mg/dL = give 5 units of insulin
Notify the physician if blood sugar is below 70 mg/dL or above 400 mg/dL.
A review of Resident 1?s MAR indicated that Resident 1?s blood sugar level was exactly 400 mg/dL between 1/18/17 and 2/15/17 for a total of 23 times.
During an interview, 6/14/17 at 12:45 p.m., the director of nursing DON stated the facility?s glucometer (a medical device used for determining the approximate concentration of glucose in the blood) could read blood sugar levels as high as 600 mg/dL. The DON could not explain why the licensed nurses documented 23 times in a month?s period that Resident 1?s blood sugar level was 400 mg/dL. The DON stated she did not believe that nursing staff would document 400 mg/dL to avoid calling the physician. The DON stated none of the nursing staffs had brought it to her attention about the possibility of glucometer malfunction with the consistent 400 mg/dL blood sugar level reading.
During a telephone interview, on 6/14/17 at 1 p.m., the glucometer manufacturer?s customer associate stated that it was an anomaly to have several incidents of blood glucose levels exactly at 400 mg/dL for a resident. The customer associate stated the likelihood that a resident?s blood sugar level would be exactly 400 mg/dL 23 times in less than a month was very low. The customer associate recommended for the facility to stop using the glucometer, request to send the glucometer back to the manufacturer an evaluation and replacement.
c. The facility failed to notify the attending physician regarding Resident?s 1 refusal of blood sugar level checks, the insulin injection, and Starlix (a tablet) to manage diabetes mellitus.
A review of Resident 1?s MAR indicated Resident 1 refused the blood sugar checks on the following dates and times:
On 1/18/17 at 6:30 a.m.
On 1/19/17 at 11:30 a.m., 4:30 p.m., and 9 p.m.
On 1/24/17 at 11:30 a.m.
On 1/29/17 at 4:30 p.m. and 9 p.m.
On 1/31/17 at 6:30 a.m.
On 2/2/17 at 11:30 a.m., 4:30 p.m., and 9 p.m.
On 1/13/17 at 11:30 a.m.
On 2/14/17 at 6:30 a.m.
The resident refused 13 times to have her blood sugar levels checked. The MAR indicated Resident 1 did not receive insulin coverage for the 13 times the resident refused to have her blood sugar levels checked. The licensed nurse would not know how many units of insulin to administer to Resident 1 because the amount of insulin coverage was dependent on the blood sugar level.
During an interview, on 4/18/17 at 12:15 p.m., the DON stated the physician should have been notified of Resident 1?s blood sugar check refusal. The DON stated the risk of refusing blood sugar checks would be hypoglycemia (low blood sugar levels that are below normal levels and can cause symptoms of confusion, loss of consciousness, or death) or hyperglycemia (high blood sugar levels that are above normal levels and can cause a medical emergency).
A review of Resident 1?s MAR indicated that the resident refused the medication Starlix (a medication used to lower levels of sugar) four times on the following dates:
On 1/27/17 at 4:30 p.m.
On 2/2/17 at 4:30 p.m.
On 2/6/17 at 6:30 a.m.
On 2/14/17 at 6:30 a.m.
The physician order was to administer Starlix 60 mg PO (by mouth), three times a day (TID) before meals (AC) for diabetes.
During an interview, on 4/18/17 at 12:15 p.m., the DON stated Resident 1?s physician should have been notified that Resident 1 refused care and to take her medications so that the physician could provide recommendations and orders.
A review of Resident 1's (COC)/ SBAR Assessment Form (situation, background, assessment, and recommendation ? a framework for communication between members of the health care team about a resident's condition), dated 2/8/17, indicated that the resident had a weight loss of 12 lbs. The resident's recorded weight was 122 lbs on 2/2/17 and 110 lbs on 2/8/17. The 110 lbs on 2/18/17 was the last recorded weight record of the resident in the facility.
There was no documented evidence an IDT meeting was conducted to address the resident?s refusal of blood tests and medications.
A review of Resident 1?s COC (Change of Condition) Assessment form, dated 2/16/17 at 3:50 a.m., indicated the resident was found unresponsive with blood sugar level of 511 mg/dL. The COC form did not indicate vital signs (important signs that indicate the status of the body?s vital functions and include blood pressure, heart rate, respiratory rate, and oxygenation) because the resident?s vital signs were unappreciated (not fully recognized). The COC form indicated the facility had made an emergency call for the paramedics for Resident 1.
According to Resident 1?s GACH emergency room (ER) report, dated 2/16/17, Resident 1 was brought in by emergency medical services (EMS/paramedics) from the skilled nursing facility pulseless status post cardiac arrest (sudden stopping of the function of the heart). Per EMS, Resident 1 was found by the facility staff at 3:50 a.m. pulseless and apneic (not breathing), and the staff started cardiopulmonary resuscitation (CPR, refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased). EMS found Resident 1 in full (cardiac) arrest at 4:03 a.m.; the resident remained asystole (no heart beat) and CPR was continued. The EMS arrived at the hospital at 4:33 a.m. Resident 1 was asystolic the entire time.
A review of Resident 1?s Certificate of Death indicated the resident died XXXXXXX17 at 4:36 a.m. Resident 1?s immediate cause of death was hypertrophic heart disease and a significant condition that contributed to her death was diabetes mellitus.
According to the facility's policy and procedure titled, "Care Plans-Comprehensive," dated September 2010, assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care Planning/ Interdisciplinary Team is responsible for the review and updating of care plans when there had been a significant change in the resident's condition and when the desired outcome was not met.
According to the facility's policy and procedure titled, "Refusal of Care and Treatment," dated 2017 indicated if the resident's refusal brings about a significant change, a reassessment will be made and such information will be incorporated into the resident's care plan; and should the resident refuse to accept care or treatment, detailed information relating to the refusal must be entered into the resident's medical record and the physician will be notified for further deem clinical interventions.
The facility failed to provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being and to ensure that residents receive treatment and care, in accordance with professional standards of practice, the plan of care, and resident?s choices; and to immediately inform and consult with Resident 1's physician, when the resident refused treatment; including but not limited to, failures to:
1. Identify the irregularities in Resident 1?s blood sugar levels and notify the director of nursing (DON) and attending physician of these irregularities.
2. Intervene and treat Resident 1?s abnormal high blood sugar levels.
3. Notify Resident 1?s attending physician that the resident refused laboratory (blood) tests, blood sugar level checks, and medications (insulin and Starlix) to manage diabetes mellitus (a chronic condition that prevents the body from getting glucose or sugar from the blood into the body's cells to use as energy, causing weight loss).
4. Conduct an interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident), with the involvement of Resident 1?s physician to address Resident 1's refusal of treatment and to develop appropriate interventions.
5. Review and revise the care plan to manage effectively Resident 1?s continued non-compliance with the treatment (laboratory or blood tests, blood sugar level checks, and medications).
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 940000116 |
SHEA REHABILITATION HEALTHCARE CENTER |
940013384 |
A |
28-Jul-17 |
M1C811 |
11953 |
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).
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:
(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 3/3/17, an unannounced abbreviated survey was conducted.
Based on interview and record review, the facility failed to provide Resident 1 with necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with his comprehensive assessment and plan of care to meet the needs of the resident, who was at risk for poor circulation and had diagnosis of deep vein thrombosis (DVT a blood clot that forms in a vein deep in the body) and venous insufficiency (the flow of blood through the veins is inadequate) by failing to:
1. Implement Resident 1's care plan, related to poor circulation of the lower extremities, to observe and report to the attending physician any changes in color, temperature, pain, sensation, or drainage of the right great toe.
2. Identify as a change of condition , Resident 1's worsening right great toe wound.
3. Implement the facility's "Change in Condition" policy to ensure the change in condition of a resident's toe wound was handled promptly and to ensure daily assessment of the wound was handled by the Nurse Supervisor under the direction of the Director of Nurses (DON).
These deficient practices resulted in Resident 1's delay of 6 days for medical evaluation and intervention for severe right leg arterial occlusive (blockage or narrowing of an artery in the legs) disease. Resident 1 was transferred to the general acute care hospital (GACH) emergency room (ER) on XXXXXXX17 at 9:27 a.m. for treatment of right great toe gangrene (death of tissue, a dangerous and potentially fatal condition). On January 9, 2017, the resident underwent a surgical balloon angioplasty (a method of opening a clogged or narrowed blood vessel) and stenting (to place a small, metal mesh tube that keeps the artery open) of the right superficial artery (artery in the thigh) and popliteal artery (artery in the knee and the back of the leg) to treat the right leg ischemia (inadequate blood supply) and right great toe gangrene (decay of flesh). On 1/10/17, Resident 1 required a right great toe amputation (surgically cutting off) for gangrene of the right great toe.
During a telephone interview, on 3/1/17 at 7:44 a.m., Resident 1's Power of Attorney (POA a responsible party for Resident 1), stated the facility notified her about the resident's right great toe problem (gangrene) on 1/5/17, when Resident 1 had been transferred to the GACH. The POA stated the resident had an amputation of the right toe and later had progressed to include an amputation of his right foot.
A review of admission record (Face Sheet) indicated Resident 1 was admitted to the facility on 10/11/16, with diagnoses that included cognitive communication deficit (disorders of communication affected by disruption of mental processes), type 2 diabetes (high levels of sugar in the blood), and thrombosis of unspecified deep veins (DVT) of the lower extremities. |
| 940000037 |
Santa Fe Heights Healthcare Center LLC |
940013389 |
A |
27-Jul-17 |
C2UH11 |
18698 |
F157- 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-
(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
F279 ? 42 CFR ?483.20(d)
(d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan.
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).
?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.
F325 ? 42 CFR ?483.25(g) Assisted nutrition and hydration.
Based on a resident?s comprehensive assessment, the facility must ensure that a resident-
(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident?s clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;
Based on interview and record review, the facility failed to provide Resident 1 with the necessary nutritional care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with the plan of care; to conduct a comprehensive assessment during a change of condition; and to immediately inform and consult with the resident's physician, conservator (a guardian appointed by a judge), and registered dietitian when the resident refused treatment; including but not limited to, failures to:
1. Notify Resident 1?s attending physician that the resident refused the prescribed diet and Nepro (a nutritional supplement drink) on seven (7) occasions; had lack of tolerance to Nepro; and had a change of condition (nausea and vomiting) for a week.
2. Notify the registered dietitian that Resident 1 had a 12-pound weight loss in one week on 2/7/17 and to evaluate the resident for further weight loss prior to her death on XXXXXXX 17; had a lack of tolerance to Nepro and refused Nepro; refused the regular meals and ate fruits and cheese instead; and vomited her food for a week.
3. Conduct an interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident), with the involvement of Resident 1?s physician, conservator and dietitian, to address Resident 1's refusal of meals, nausea and vomiting, and weight loss; and to develop appropriate interventions.
4. Review and revise the care plan to manage effectively Resident 1?s continued non-compliance with prescribed diet.
Resident 1, who had a mental illness and type 2 diabetes mellitus (a chronic condition that prevents the body from getting glucose or sugar from the blood into the body's cells to use as energy, causing weight loss), had a behavior of refusing the ordered therapeutic diet (a meal plan that is part of a treatment of a medical condition that is prescribed by the physician and planned by a registered dietitian). The facility allowed Resident 1, who was already at risk for weight loss due to diabetes mellitus, to refuse the ordered diet, without involving the physician, the resident?s conservator, and the dietitian. The facility did not conduct an interdisciplinary team (IDT) meeting, with the participation of the physician, conservator, and dietitian, to discuss the resident?s refusal of the diet and change of condition (nausea and vomiting).
These deficient practices resulted in Resident 1's avoidable weight loss of 12 pounds (lbs) in one week, and unmonitored further weight loss. The resident died on XXXXXXX17 after a stay of 30 days at the facility (from XXXXXXX17 to XXXXXXX17) with a total weight loss of 14 lbs (from 121 lbs at admission to 107 lbs at the time of death) and diabetes mellitus was a significant condition that contributed to the resident?s death.
A review of Resident 1?s History and Physical (H &P) from a general acute care hospital (GACH), dated 1/5/17, indicated Resident 1 had a past medical history of noncompliance with medications and treatment, and refusal of care.
A review of Resident 1's Face Sheet (admission record) indicated that the resident was a 48-year-old female, who was admitted to the facility on XXXXXXX17 at 9 p.m. with diagnoses that included but not limited to type 2 diabetes mellitus and schizophrenia (a mental disorder). Resident 1?s admission weight was 121 lbs. Resident 1 had a conservator.
A review of Resident 1's Minimum Data Set (MDS, a resident and care screening tool), dated 2/27/17 indicated the resident?s cognition (ability to reason and think) was intact; the resident exhibited the behavior of rejecting care one to three days within seven days; and she required supervision and set up help for eating.
A review of Resident 1?s diet order on 1/18/17 indicated a diet change to regular, NCS (no concentrated sweets), NSPOT (no salt package on tray) , low potassium, renal diet, and no dairy products. There was no physician?s order found in the medical record to reflect the diet modification of NCS and low potassium.
A review of Resident 1's Nutritional Status care plan, initiated on 1/17/17, indicated the goals developed were to ensure that the resident will consume greater than 75% of meal served daily for 90 days and to minimize significant weight change of five (5) lbs (plus and/or minus) monthly for 90 days. The care plan indicated to give Resident 1 a diet as ordered, monitor meal intake daily, and to provide a registered dietician consult with follow up as needed. The care plan did not indicate that Resident 1 had a preference for fruits and was receiving fruit plate.
A review of Resident 1's non-compliant behavior care plan, initiated on 1/23/17, indicated the resident was non-compliant with dietary orders/ restriction and was refusing to take prescribed treatment.
A review of Resident 1's Nutritional Assessment: Dietitian Section, dated 1/24/17, indicated a handwritten check mark that the resident was at high risk for excessive weight loss/gain. The assessment indicated that Resident 1's weight was 121 lbs and her ideal body weight range was 112 to 138 lbs. The assessment indicated the plan for Resident 1 was to provide Nepro one (1) can daily at 2 p.m.
A review of Resident 1's physician's order, dated 1/26/17 at 10:05 a.m., indicated to give the resident Nepro one can daily at 2 p.m.
A review of Resident 1' Medication Administration Record (MAR) for January and February 2017, indicated the resident refused Nepro for seven days out of the 14 days on 1/30/17, 1/31/17, 2/1/17, 2/4/17, 2/7/17, 2/10/17, and 2/12/17. The resident's documented reason was "I can't take that, I'll throw up."
During an interview, on 3/13/17 at 11:45 a.m., a certified nursing assistant (CNA 2) stated Resident 1 would have episodes of nausea and vomiting during the month of February. CNA 2 stated she observed Resident 1 with nausea after medication administration and before meals. CNA 2 stated that Resident 1 would vomit after she had tasted her meal.
During an interview on 3/13/17 at 12:50 p.m., Housekeeper 1 stated she observed Resident 1 vomiting in the trash bin frequently.
During an interview, on 3/13/17 at 1:30 p.m., a licensed vocational nurse (LVN 2) stated she was aware that Resident 1 had nausea and vomiting. LVN 2 stated Resident 1 would vomit after medication administration. LVN 2 stated vomiting medications would be a change of condition for Resident 1. LVN 2 stated Resident 1?s change of condition of vomiting medications should have been documented in the progress notes and change of condition (COC) form.
A review of Resident 1's Nutritional Screening & Data Collection Form indicated that on 2/8/17, Resident 1 refused to eat regular meals and the resident requested fruit plate for lunch and dinner.
A review of Resident 1's (COC)/ SBAR Assessment Form (situation, background, assessment, and recommendation ? a framework for communication between members of the health care team about a resident's condition), dated 2/8/17, indicated that the resident had a weight loss of 12 lbs. The resident's recorded weight was 122 lbs on 2/2/17 and 110 lbs on 2/8/17. The 110 lbs on 2/8/17 was the last recorded weight record of the resident in the facility.
During an interview, on 3/13/17 at 11:20 a.m., a certified nurse assistant (CNA 1) stated that she had observed that Resident 1 would eat 60% of the breakfast meal and lunch, but would eat most of a plate of fruit that consist of watermelon, cantaloupe, and honeydew melon.
During an interview on 3/13/17 at 4 p.m., a registered nurse (RN 1) stated Resident 1 would eat 20% of her dinner (regular diet) meals. On 3/15/17 at 10:10 a.m., during an interview, RN 1 stated that Resident 1 had a behavior of refusing her meals.
During an interview, on 3/15/17 at 2 p.m., the dietary service supervisor (DSS) stated Resident 1 would request for fruit plates, banana, orange, milk, and cottage cheese, and the dietary staff would provide it for the resident because the resident would only eat those food items. The DSS stated Resident 1 would rarely eat the meal tray and mostly ate the fruit plate. The DSS stated Resident 1 was given her prescribed meal for breakfast and a fruit plate with cottage cheese for lunch and dinner.
During the interview, the DSS stated that there was no registered dietitian?s (RD's) evaluation note that addressed the resident's weight loss of 12 lbs. on 2/8/17 (a Wednesday). On 6/13/17 at 2 p.m., the DSS stated she did not tell anybody that resident was served fruit plates for lunch and dinner.
During an interview and concurrent record review of Resident 1's health record, on 3/15/17 at 10:10 a.m., RN 1 stated there were no IDT meetings conducted to address the resident's weight loss of 12 lbs. and refusal of the prescribed diet and the resident's request for fruit plate.
During an interview, on 4/18/17 at 7:10 a.m., the RD stated that the facility should have requested for resident nutritional evaluation for concerns related to the nutritional status of a resident such as weight loss, lack of tolerance to food and supplement, poor nutritional intake, nausea and vomiting, and resident refusing meals. The RD stated that she was not made aware that Resident 1 had a 12-pound weight loss in one week and lacked the tolerance to Nepro supplement with nausea and vomiting.
During the interview, the RD stated that if she had been made aware of Resident 1's nutritional concerns, then she (the RD) would have recommended another supplement substitute for Nepro, an appetite stimulant, and to have the resident transferred to an acute hospital for evaluation. The RD stated that the facility should have made a request for an RD to re-evaluate Resident 1 so that the facility could meet the resident's nutritional needs. The RD stated a fruit plate was not adequate enough for a well- balanced diet.
During interview and concurrent record review of Resident 1's non-compliant behavior care plan (dated 1/23/17), on 4/18/17 at 12:15 p.m., the director of nursing (DON) stated the resident's care plan should have been updated to include additional specific interventions to address the resident's continued refusal of medication, treatment, and diet, such as resident refused Nepro and blood sugar checks.
During an interview and concurrent record review of Resident 1's Medication Administration Record (MAR), on 4/18/17, the DON stated that the facility should have investigated the cause of Resident 1's lack of tolerance to Nepro, and the resulting nausea and vomiting. The DON stated that a resident who vomits constitutes a change of condition (COC) that would have necessitated a transfer of the resident to an acute hospital. The DON stated that the COC should have been reported to the physician and followed up with the facility's chain of command so that care and services could be provided. The DON stated the facility should have referred the resident to the RD for evaluation and to obtain recommendations to prevent further weight loss.
A review of Resident 1?s COC (Change of Condition) Assessment form, dated 2/16/17 at 3:50 a.m., indicated the resident was found unresponsive with blood sugar level of 511 mg/dL (milligrams per deciliter). The COC form did not indicate vital signs (important signs that indicate the status of the body?s vital functions and include blood pressure, heart rate, respiratory rate, and oxygenation) because the resident?s vital signs were unappreciated (not fully recognized). The COC form indicated the facility had made an emergency call for the paramedics for Resident 1.
According to Resident 1?s GACH emergency room (ER) report, dated 2/16/17, Resident 1 was brought in by emergency medical services (EMS/paramedics) from the skilled nursing facility pulseless status post cardiac arrest (sudden stopping of the function of the heart). Per EMS, Resident 1 was found by the facility staff at 3:50 a.m. pulseless and apneic (not breathing), and the staff started cardiopulmonary resuscitation (CPR, refers to any medical intervention used to restore circulatory and/or respiratory function that has ceased). EMS found Resident 1 in full (cardiac) arrest at 4:03 a.m.; the resident remained asystole (no heart beat) and CPR was continued. The EMS arrived at the hospital at 4:33 a.m. Resident 1 was asystolic the entire time.
A review of Resident 1?s Certificate of Death indicated the resident died XXXXXXX17 at 4:36 a.m. and a significant condition that contributed to the death of the resident was diabetes mellitus.
According to the facility's policy and procedure titled, "Care Plans-Comprehensive," dated September 2010, assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care Planning/ Interdisciplinary Team is responsible for the review and updating of care plans when there had been a significant change in the resident's condition and when the desired outcome was not met.
According to the facility's policy and procedure titled, "Change in a Resident's Condition or Status," dated November 2015, the Nurse Supervisor/ Charge 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; and a need to alter the resident's medical treatment significantly; and refusal of treatment or medications.
A review of the facility's undated policy and procedure titled "The Weight Assessment and Intervention," indicated the policy indicated the Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss.
According to the facility's policy and procedure titled, "Refusal of Care and Treatment," dated 2017 indicated if the resident's refusal brings about a significant change, a reassessment will be made and such information will be incorporated into the resident's care plan; and should the resident refuse to accept care or treatment, detailed information relating to the refusal must be entered into the resident's medical record and the physician will be notified for further deem clinical interventions.
The facility failed to provide Resident 1 with the necessary nutritional care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with the plan of care; to conduct a comprehensive assessment during a change of condition; and to immediately inform and consult with the resident's physician, conservator (a guardian appointed by a judge), and registered dietitian when the resident refused treatment; including but not limited to, failures to:
1. Notify Resident 1?s attending physician that the resident refused the prescribed diet and Nepro (a nutritional supplement drink) on seven (7) occasions; had lack of tolerance to Nepro; and had a change of condition (nausea and vomiting) for a week.
2. Notify the registered dietitian that Resident 1 had a 12-pound weight loss in one week on 2/7/17 and to evaluate the resident for further weight loss prior to her death on 2/16/17; had a lack of tolerance to Nepro and refused Nepro; refused the regular meals and ate fruits and cheese instead; and vomited her food for a week.
3. Conduct an interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident), with the involvement of Resident 1?s physician, conservator and dietitian, to address Resident 1's refusal of meals, nausea and vomiting, and weight loss; and to develop appropriate interventions.
4. Review and revise the care plan to manage effectively Resident 1?s continued non-compliance with prescribed diet.
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 940000037 |
Santa Fe Heights Healthcare Center LLC |
940013390 |
B |
27-Jul-17 |
C2UH11 |
11260 |
42 CFR ?483.10(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:
?483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.
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-
(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
Based on interview and record review, the facility failed to exercise Resident 1?s rights by failing to:
1. Implement the Resident 1?s case manager?s instruction to transfer Resident 1 to a suitable facility (a locked facility) to receive mental health treatment in accordance with the Letters of Conservatorship (an Order by the court naming a guardian or conservator for a person suffering from a mental disorder).
2. Obtain an informed consent from Resident 1?s conservator regarding admission, vaccinations, and the use of psychoactive medications (mind-altering medications).
3. Notify Resident 1?s conservator of the resident?s refusal of treatment and diet order and change of condition, such as weight loss and having nausea and vomiting.
Resident 1, who had a mental illness and who had a behavior of refusing treatment and the prescribed diet, was not transferred by the facility to a suitable facility that could manage her mental illness. The facility staff was allowing the resident to refuse treatment, without notifying and involving the resident?s conservator. The physician, dietary service supervisor, and registered dietitian were not aware the resident was conserved. The social service director and a licensed psychiatric technician (LPT 1) were aware that the resident was conserved. The facility staff, who had knowledge that the resident was conserved, did not understand that Resident 1 did not have the right or consent to treatment related specifically to her being gravely disabled in accordance with the Letters of Conservatorship.
These deficient practices resulted in a violation of Resident 1's rights.
A review of Resident 1?s Letters of Conservatorship, executed on 1/21/16 until 1/21/17, indicated the court finds that Resident 1 (the conservatee), as a result of mental disorder, was gravely disabled person and unable to provide for her basic personal needs for food, clothing or shelter and Resident 1 was either unwilling or incapable of accepting treatment voluntarily. The Letters of Conservatorship indicated Resident 1 shall not have the right to refuse or consent to medical treatment unrelated to the Resident 1?s being gravely disabled and Resident 1 shall not have the right to refuse or consent to treatment related specifically to Resident 1 being gravely disabled. The terms of the conservatorship required that Resident 1 be kept in a locked treatment center.
On 6/16/17 at 10:50 a.m., during a telephone interview, the Program Manager of the Office of the Public Conservator stated a continuance of conservatorship was requested and granted for the resident to remain under conservatorship until her court appointment on 4/6/17 for reestablishing conservatorship.
During the interview, the Program Manager stated Resident 1 could not make decisions for herself and the resident did not have the right to refuse medical treatment. The Program Manager stated conservators were responsible for making decisions related to medical care and consents, and legal matters for the resident.
A review of Resident 1's Face Sheet (admission record) indicated that the resident was a 48-year-old female, who was admitted to the facility on XXXXXXX17 at 9 p.m. with diagnoses that included but not limited to type 2 diabetes mellitus (a chronic condition that affects the way the body metabolizes blood sugar, the body's source of energy) and schizophrenia (a mental disorder). Resident 1?s admission weight was 121 pounds (lbs).
Resident 1?s Face Sheet indicated her responsible party was a guardian (or public guardian/conservator). Resident 1?s second contact person was a case manager (an individual appointed and assigned by the court through a legal process to manage daily matters such as care and medical appointments for a gravely disabled individual).
There was no documented evidence the facility obtained a copy of Resident 1?s Letters of Conservatorship.
During an interview, on 6/13/17 at 2 p.m., the dietary service supervisor (DSS) stated she was not aware that the resident was under conservatorship.
During a telephone interview, date 6/13/17 at 3:10 p.m., the registered dietitian (RD) stated she did not know Resident 1 had a conservator and that the resident was incapable to make decisions. The RD stated the nursing services should take care of the conservatorship related issues. The RD stated Resident 1 had a right to choose not to follow the diet prescription.
During an interview, 6/13/17 at 4:15 p.m., the social service director (SSD) stated she was aware that Resident 1 was under conservatorship, but the SSD did not have a copy of the order for conservatorship.
During an interview, on 6/20/17 at 10:10 a.m., Resident 1?s attending physician stated he was not aware that Resident 1 was under conservatorship.
A review of Resident 1's Minimum Data Set (MDS, a resident and care screening tool), dated 2/27/17 indicated the resident?s cognition (ability to reason and think) was intact; the resident exhibited the behavior of rejecting care one to three days within seven days; and she required supervision and set up help for eating.
A review of the social service notes, dated 1/19/17, indicated that a case manager (CM 1) for mental health for Resident 1 requested that Resident 1 be transferred to a locked facility due to a risk of elopement. The SSD documented that she had informed Resident 1, who stated she liked the facility and she did not want to go to another facility. The SSD notes indicated that on 1/20/17, CM 1 visited the facility to discuss transferring Resident 1 to a locked facility.
During an interview, on 6/16/17 at 10:50 a.m., the Program Manager of the Office of the Conservator (CM 1?s supervisor) read the documentation of CM 1. CM 1 documented (on the record at the Conservator?s office) that on 1/19/17, she had been made aware Resident 1 was in an unlocked facility and was at risk for AWOL (absence without leave or elopement). CM 1 documented meeting with the SSD and the director of nursing (DON) on 1/20/17 to request Resident 1?s transfer to a locked facility due to ?high blood glucose, not stable.? CM 1 documented there was no doctor?s order for transfer.
During an interview, on 6/19/17 at 2:30 p.m., the SSD stated it ?did not make any sense? why CM 1 wanted the resident transferred to a sister facility (a locked facility). The SSD stated that the facility did not have a transfer order from the physician after CM 1?s visit and that she (the SSD) would follow up on the following Monday. There were no other notes from the SSD following the CM 1?s visit. The SSD stated she did not request the transfer of Resident 1 to the locked psychiatric facility.
During interview, on 6/14/17 at 3:10 p.m., LPT 1 was asked whom did she call to verify that the physician obtained informed consents for the psychoactive medications, Risperdal (an antipsychotic medication), Divalproex (a medication used to treat manic phase of a bipolar disorder), and Ativan (an anti-anxiety medication) prescribed for Resident 1 at admission. LPT 1 stated she had left a message to Resident 1?s conservator and she did not receive any return call. LPT 1 stated she documented incorrectly on Resident 1?s informed consent forms regarding receiving consents for Risperdal, Divalproex, and Ativan.
During an interview and a review of Resident 1?s medical records, on 6/14/17 at 12:45 p.m., the DON stated she did not see informed consents for Resident 1?s vaccinations.
There was no documented evidence that facility staff received informed consents from the conservator?s office regarding Resident 1?s admission, vaccinations, and psychoactive medications.
A review of Resident 1's non-compliant behavior care plan, initiated on 1/23/17, indicated the resident was non-compliant with dietary orders/ restriction and was refusing to take prescribed treatment.
A review of Resident 1's Nutritional Screening & Data Collection Form indicated that on 2/8/17, Resident 1 refused to eat regular meals and the resident requested fruit plate for lunch and dinner.
A review of Resident 1's (COC)/ SBAR Assessment Form (situation, background, assessment, and recommendation ? a framework for communication between members of the health care team about a resident's condition), dated 2/8/17, indicated that the resident had a weight loss of 12 lbs. The resident's recorded weight was 122 lbs on 2/2/17 and 110 lbs on 2/8/17. The 110 lbs on 2/18/17 was the last recorded weight record of the resident in the facility.
During an interview, on 3/15/17 at 2 p.m., the DSS stated she did not inform the conservator that Resident 1 was refusing the diet order and requesting fruit plates. The DSS stated she did not tell anybody that Resident 1 was served fruit plates for lunch and dinner.
During an interview and concurrent record review of Resident 1's health record, on 3/15/17 at 10:10 a.m., a registered nurse (RN 1) stated there were no interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident) meetings conducted to address the resident's weight loss of 12 lbs. and refusal of the prescribed diet and the resident's request for fruit plate. There was no documented evidence an IDT meeting was conducted to address the resident?s refusal of blood tests and medications.
The facility failed to exercise Resident 1?s rights by failing to:
1. Implement the Resident 1?s case manager?s instruction to transfer Resident 1 to a suitable facility (a locked facility) to receive mental health treatment in accordance with the Letters of Conservatorship (an Order by the court naming a guardian or conservator for a person suffering from a mental disorder).
2. Obtain an informed consent from Resident 1?s conservator regarding admission, vaccinations, and the use of psychoactive medications (mind-altering medications).
3. Notify Resident 1?s conservator of the resident?s refusal of treatment and diet order and change of condition, such as weight loss and having nausea and vomiting.
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 1. |
| 950000061 |
Sunny View Care Center |
950008966 |
B |
01-Feb-12 |
36GN11 |
5036 |
72345 Dietetic ? Sanitation. (a) All kitchens and kitchen areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. On 7/11/11, at 10:20 a.m., an unannounced visit was made to the facility to investigate a complaint regarding dietetic services. Based on observation, interview, and record review, the facility failed to maintain a clean kitchen area by failing to:1. Ensure that the kitchen was kept clean and free from debris. This condition predisposed the facility to rodents and vermin.2. Develop policies and procedures to be used by the food service staff to guide and instruct inthe cleaning and sanitation of the kitchen area.According to the administrator on 7/11/11, at approximately 11:40 am, a new food management company had recently taken over the operations of the dietary services area on 7/1/11. Upon arrival at the facility?s kitchen on 7/11/11at 10:30 a.m., the following observations were made: The hand washing sink was observed stained with brownish oily residue and several areas encrusted with what appeared to be coffee ground-like substancesin the bottom of the sink. The evaluator also observed a used ?Band-Aid? that was lying near the kitchen drain.At approximately 10:35 a.m., the wall of the ice cream freezer was observed with a yellowish brown colored substance that had become frozen. The bottom of the freezer had piles and areas of frozen and speckled frozen food debris.At approximately 10:55 a.m., the evaluators observed three large bins containing rice, sugar, and food thickener with dried and encased food-like substances and lids that contained unidentifiable brown, black and white crumb residue that were grimy and sticky to touch.At approximately 10:56 a.m., the evaluator noted that the stainless steel shelves and racks of the reach-in refrigerators by the fryers were encrusted with unidentifiable but removable brown food substances.At approximately 11:00 a.m., the evaluator noted that the kitchen fryer was equipped with five fryer baskets. The baskets were observed with encrusted and unidentifiable food substances. The evaluator further noted an opened container of used grease that was stored on the floor behind the fryer.The Registered Dietitian (RD) stated during an interview on 7/11/11, at 11:00 a.m. that she could not state when the last time the fryer was used. The RD stated the staff that worked over the weekend was not presently available in the facility. The RD stated that the fryer should have been cleaned. At approximately 11:15 a.m., the walk-in refrigerator was observed with numerous lumps of dried and loose crumbs on the floor and walls of the walk-in refrigerator. The evaluator also noted that the floor of the walk-in refrigerator was dirty and in disrepair as evidenced by the observation of broken floor tiles that were encased in dark brown grimy substances in the grout lines. The back wall by the right side of the walk-in refrigerator was observed with chunks of what appeared to be spilled dried food substances that ran the entire length of the wall surface down to the floor.At approximately 10:40 a.m., two glue mouse traps were observed on the floor by the dish machine and at 11:16 a.m., the evaluator observeda mouse trap on the shelf in the walk-in dry storage area.Review of the pest control report dated 5/11/11, revealed there was grease build up in, on and behind the cook lines. It also identified the presence of cockroaches behind the cabinet in the pantry, a rat during service and rat droppings under the storage rack behind the prep sink and on top of the cook lines.The Registered Dietitian (RD) stated during an interview on 7/11/11, at 10:55 a.m., that the mouse traps had been in the corner since they (contracted dietary company) had taken over the food service at the facility. Again during another interview with the RD on 7/11/11, at 11:20 a.m., the RD stated that she did not know if a cleaning schedule existed. The RD stated all of the staff members were cross trained in all the different positions in the kitchen.The facility was unable to provide any documented evidence that the facility had developed approved policies and procedures to address the cleaning and sanitation of the facility?s kitchen. The overall appearance of the kitchen demonstrated uncleanliness of the food preparation and service area. Therefore, the facility failed to: 1. Ensure that the kitchen was kept clean and free from debris. This condition predisposed thefacility to rodents and vermin.2. Develop policies and procedures to be used by the food service staff to guide and instruct in the cleaning and sanitation of the kitchen area.The facility?s failure to ensure that the kitchen was kept clean placed all patients who eat meals in the facility at risk of developing a food borne illness. This violation had a direct or immediate relationship to the health, safety or security of patients. |
| 950000061 |
Sunny View Care Center |
950008968 |
B |
01-Feb-12 |
36GN11 |
7849 |
72335. Dietetic Service ? Food Service (a) The dietetic service shall provide food of the quality and quantity to meet each patient's needs in accordance with the physicians' orders and to meet "The Recommended Daily Dietary Allowance," the most current edition, adopted by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences, and the following: On 7/11/11 at 10:20 a.m., an unannounced visit was made to the facility to investigate a complaint regarding dietetic services. Based on observation, interview, and review of facility documents, the facility failed to: 1) Ensure food was provided of the quality and quantity to meet each patient's needs in accordance with the physicians? orders and to meet ?The Recommended Daily Dietary Allowance.?According to the administrator on 7/11/11 at approximately 11:40 am, a new food management company had recently taken over the operations of the dietary services area on 7/1/11. On 7/11/11 at 10:45 a.m., the Surveyor observed that there was one sheet pan in the reach-in refrigerator containing peanut butter and jelly sandwiches and ham sandwiches. The sandwiches were observed to contain very little ham and very little peanut butter on them. On 7/11/11 at approximately 10:47 a.m., an interview was conducted with the dietary staff B regarding the sandwiches. Dietary staff B stated she makes the sandwiches for lunch and dinner if residents request them or if they do not like the hot entree. On 7/11/11 at 11:30 a.m., the Surveyor asked dietary staff A to weigh the amount of ham that was on the sandwich. Dietary staff A weighed the ham and it was 3/4 of an ounce of meat (one ounce equals seven grams of protein). The ham sandwich was prepared on whole wheat bread and contained no fat or dressing.The peanut butter and jelly sandwiches were prepared with a very thin layer of peanut butter spread on them.An interview was conducted at this time, with the Registered Dietitian (RD) regarding the amount of protein contained in the sandwiches. The RD stated there should be two tablespoons of peanut butter on the sandwich. When asked, the RD demonstrated that the peanut butter only had a light smear across the bread. The RD stated the menu provides on average about three ounces of meat (21 grams of protein) for lunch and dinner. The RD was not able to verbalize how much peanut butter was needed to be a substitute for three ounces of protein for lunch. The surveyor asked the RD for the recipes for the sandwiches. The RD stated she could notfind any recipes at that time. On 7/11/11 at approximately 4:30 p.m., five hours later, the recipes were provided. A Review of the recipe for the ham and cheese sandwich indicated to provide two ounces of ham and one slice of cheese. However, the ham sandwiches that were observed did not contain any cheese and only had 3/4 of an ounce of ham. The review of the nutrient analysis of the ham-and-cheese sandwich showed, that the sandwich provided 17.2 grams of protein. An equal substitute of protein for lunch or dinner should be 21 grams of protein; the observed ham sandwich only contained approximately 5 grams of ham.A review of the recipe for the peanut butter and jelly sandwich indicated to provide one and a half ounce of peanut butter on one slice of bread. However, the peanut butter sandwiches that were observed had only a thin smear of peanut butter. A review of the nutrient analysis of the peanut butter and jelly sandwich revealed that the sandwich provides 14.2 grams of protein. An equal substitute of protein for lunch or dinner should be 21 grams of protein; it was unclear how much protein the peanut butter sandwich that was observed contained.During a tray line observation of the lunch meal on 07/11/11, at approximately 12:00 pm, Dietary staff A was observed serving meals without the ?Production Menu Sheet? that indicated the amounts of food for each item served for specific diets. This was not a requirement but was a standard of practice that the production sheet that indicated the amounts of food for each item served for specific diets be available and as aworking reference during meal service. During the lunch tray line meal service, the evaluator noted that pureed beef, pureed vegetables, and mashed potatoes were placed in the steam table. Other food items observed in the steam table included beef stew, steamed rice, and steamed Capri vegetables. The evaluator further noted that the kitchen Dietary staff A used the « cup (4 ounces) scoop to dish out the food items for regular portions and ¬ cup (two ounces) scoop for patients who had requested small portions. During an interview at approximately 12:02 pm on 7/11/11, with Dietary staff A about how the amount of food served to the patients was determined, he stated that the amount served was based on what had been served in the past. The RD was asked at approximately 12:40 p.m for a copy of the production sheet to help the staff determine the correct portion sizes. Review of the production sheet, revealed that the pureed beef should have been three ounces instead of four ounces. There was no documented portion sizes listed on the production sheet for small portions. A review of the menu dated 7/10/11, through 7/16/11, revealed that the different diets noted on the menu did not have portion sizes listed next to the menu items. Also, the menus did not contain a list of the portion sizes for patients requesting smaller portions. The RD provided no additional information when she was asked why there was no production sheet for use by the tray line staff. The facility failed to provide instructions to the food service staff to help determine the correct portion sizes to be served to patients of the facility. A review of the personnel record of Dietary Staff A and D was conducted and revealed that neither staff had received training related to their job duties.During an interview with the Registered Dietitian on 7/11/11, at approximately 11:00 am she stated that the facility did not have a diet manual. A review of the facility?s menus revealed that the facility serves the following diets Regular, Consistent Carbohydrate, Cardiac Diet, Pureed diet, Soft, Renal diet and, Pureed Consistent Carbohydrate Diet.The diet manual is the framework that incorporates the different types of therapeutic diets routinely ordered at the facility and is consistently used as guidance for ordering and preparing patient diets, and is in accordance with the current national standards such as the RDA or DRI.In order to ensure the menu meets the nutrition needs of the patients in the facility, the community standard is that menus are analyzed for nutrient adequacy.The facility was unable to provide any evidence of the nutrient analysis of all of the diets provided by the kitchen. The fact that staff was making arbitrary decisions on small portions, puree diets, how much protein to put on sandwiches makes it unclear how the nutrient needs of the patients are being met. It is unclear what criteria were used to determine the nutrient adequacy of the diets provided to the patients.Therefore, the facility failed to: 1) Ensure food was provided in the quality and quantity to meet each patient's needs in accordance with the physicians? orders and to meet ?The Recommended Daily Dietary Allowance.? The facility?s failure to ensure that the dietary staff prepared meals in a manner that was consistent with the community standard of quality and quantity to meet each patient?s nutritional need, placed all patients who eat meals provided by the facility at risk for weight loss and malnutrition. These violations had a direct or immediate relationship to the health, safety or security of patients. |
| 950000105 |
SUNSET MANOR CONVALESCENT HOSPITAL |
950009365 |
B |
15-Jun-12 |
IC4M11 |
5925 |
F223 483.13 (b) The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. F223 483.13 (c) (1) (i) The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.The above violation was noted during an on-site investigation as a result of a self-reported incident that was initiated on April 7, 2010.Based on interview and record review, the facility failed to ensure that Resident 1 was not subjected to sexual abuse of any kind by failing to ensure Certified Nurse Assistant (CNA) 1 did not touch or kiss the resident in accordance with the facility?s policy and procedure regarding Elder / Dependent Adult Abuse.Findings: A review of the admission record information indicated Resident 1 was a 65 year old female resident who was admitted to the facility on April 25, 2009, with diagnoses that included diabetes mellitus (high sugar in the blood), chronic obstructive pulmonary disease (refers to a group of lung diseases) and hypertension (high blood pressure).According to the physician?s annual physical examination and history report dated September 25, 2009, Resident 1 had the capacity to understand and make decisions.A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool) dated February 15, 2010, indicated that Resident 1 was independent in cognitive (mental) skills for daily decision making, had no short term or long term memory problems and required total assistance with transfers. The MDS also indicated that the resident did not have any inappropriate behavior.On April 7, 2010, at 9:35 am, the Surveyor interviewed Resident 1. During the interview, Resident 1 stated to the Surveyor that CNA 1, who worked during the 11 p.m. to 7 a.m. shift, came into her room one night on an unspecified date, at 1:30 a.m. and ?kissed me on the left check and blew kisses to me from the door.? Resident 1 also stated, ?One time he kissed me below my lips and below my neck.? The resident further stated ?this happened 3 to 4 times already and started about three weeks before. I never told anyone this before, only this morning. The first time this happened, I told him to stop it. My feeling about this, it made me feel sick.? On April 8, 2010, at 11 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, he stated that on April 7, 2010 around 10 a.m., the resident stated, ?I want to go to the Group Interview with the Surveyors and talk about the CNA who works during the 11 p.m. to 7 a.m. shift, and who put his cheek to my left cheek about three weeks ago.? LVN 1 asked the resident why she waited until now to notify the facility staff about the behavior of the CNA. According to LVN 1, Resident 1 stated to him that she did not want CNA 1 to get in trouble.On April 8, 2010 at 11:05 a.m., CNA 1 was interviewed by the Surveyor. CNA 1 stated that he had worked at the facility for three months.CNA 1 also stated that he had not kissed any residents. CNA 1 stated he was aware of the facility?s abuse protocol and had received the abuse prevention in-service training last on April 5, 2010. CNA 1 further stated that he resigned from his work at the facility, on an unspecified date, rather than be terminated.A review of CNA 1?s personnel file indicated, that the CNA was hired on December 28, 2009. The personnel file also indicated that CNA had received, read, and understood the facility?s policy for Alleged Abuse Investigation, Resident and Family Abuse Education, and Abuse Prevention, including sexual abuse, on December 28, 2009.CNA 1?s Employee Performance Evaluation dated March 28, 2010, for the Job Performance revealed that CNA 1,? needed supervision of the necessary job routine.?A review of the facility?s Investigation Report dated April 9, 2010, written by the administrator, indicated that Resident 1 reported on April 7, 2010, that a male CNA kissed her on the cheek, neck, and shoulder. The investigation report indicated that upon the conclusion of the investigation, the allegation of abuse was found to be unsubstantiated however; the Investigation Report indicated that CNA 1 was terminated from his employment at the facility in the best interest of Resident 1?s feeling of security.During an interview with the director of staff developer (DSD) on August 24, 2010, at 1:20 p.m., she stated she was unaware that Resident 1 had concerns regarding how CNA 1 treated Resident 1.On March 8, 2012, at 2 p.m., the Surveyor attempted to interview Resident 1 at the skilled nursing facility (SNF). However, according to the director of nursing (DON), Resident 1 was transferred to the acute hospital on November 20, 2011, and did not return to the SNF. During a follow-up telephone interview with LVN 1 on April 16, 2012, at 11 a.m., he stated that Resident 1 had not made any prior complaints regarding abuse of any kind, specifically sexual abuse. LVN 1 also stated that Resident 1 had not made any false allegations and the resident had always been credible with her statements.The facility?s policy and procedure dated October 2008, titled Elder / Dependent Adult Abuse, indicated the following: This community will enforce a non-tolerance of any form of behavior that might be construed as abuse by any individual ?staff member? Definitions of Types of Abuse: ?Sexual Abuse: Inappropriate touching? sexual assault, sexual harassment.The facility failed to ensure that Resident 1 was not subjected to sexual abuse of any kind by failing to ensure Certified Nurse Assistant (CNA) 1 did not touch or kiss the resident in accordance with the facility?s policy and procedure regarding Elder / Dependent Adult Abuse.The above violation has a direct relationship to the health, safety, or security of the resident. |
| 950000085 |
SANTA ANITA CONVALESCENT HOSPITAL |
950009379 |
B |
27-Jun-12 |
56LI11 |
12515 |
483.25 (h) (2) Accidents (2) The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. On October 23, 2008, at 10 a.m. an unannounced visit was made to the facility to investigate an entity reported incident which indicated that Resident 1 was noted to have redness on her head, ears and back of her neck as a reaction to a hooded hair dryer.Based on observation, interview, and record review, the facility failed to ensure that Resident 1 received adequate supervision to prevent injury by failing to: 1. Follow and apply the electric hooded hairdryer safety instructions that indicated that close supervision be provided to an invalid resident (Resident 1) while under the hooded hair dryer.2. Utilize an alternative means to dry the hair of Resident 1, who was incapable of communicating her safety needs and was constantly moving and thrashing about while seated under the hooded hair dryer.3. Develop a written care plan that contained interventions that addressed the risk factors associated with the use of an electric hooded hairdryer and those residents having fragile skin such as Resident 1.4. Follow the established and agreed upon plan between Employee 1 and Family Member 1 that beauty salon services would be provided to Resident 1 only when Family Member 1 was present to assist because Employee 1 was not experienced in providing hair care services for African-American hair-type.5. Ensure Resident 1 who was constantly moving around thrashing about while under the hooded dryer, was not left under the under the dryer for 40 minutes.And as result, Resident 1 sustained an acute thermal first degree burn to the head, ears and neck and was transferred to the acute hospital Emergency room for treatment.A review of the medical record indicated that Resident 1 was a 91 years old female who was admitted to the facility on 6/6/2007, with diagnoses that included diabetes (high blood sugar in the blood), hypertension (High blood pressure), and late effect cerebrovascular disease (Cerebrovascular disease refers to a group of conditions that affect the circulation of blood to the brain, causing limited or no blood flow to affected areas of the brain).During an observation on 10/23/08, at 10:15 a.m. Resident 1 was observed sitting in a wheelchair, and was alert, and confused. A dried healing wound was noted on the top of the resident?s head, neck, and ears. A review of the facility?s in-house investigation dated October 16, 2008, indicated that a CNA came to Resident 1?s room and noticed redness to her head, neck and ears. She therefore notified another CNA who in turn told the Charge nurse. It further noted that Family Member 1 came to visit and noticed that the resident had been burned on her head, ears and neck and immediately went to notify the charge nurse.During an interview with the Family Member 1 on October 22, 2008, she stated that on October 16, 2008, between 10 a.m. and 12 p.m. Resident 1 was taken to the facility?s beauty shop. Resident 1 was brought back to her room about 1 p.m. Family member 1 arrived to the facility at approximately 2 p.m. and Resident 1?s face was ?red as if lipsticks were painted all over her face and her hair was curled. Family Member 1 stated that she spoke with Employee 2 and the physician was contacted and ordered to transfer Resident 1 to the emergency room. Family Member 1 also stated that the ambulance attendant told her that Resident 1 had first and second degree burns on her forehead, ears and neck. She further stated that one of the staff told her that this was the third time Resident 1 had been burned and other residents have been burned by the facility?s hairdresser Staff 1. Lastly, Family Member 1 stated due to the fact that Resident 1 was ?Black? and Staff 1 was ?Hispanic? she would therefore, have Family Member 2 assist with the grooming of Resident 1?s hair. During an interview with the Director of Nursing on 10/23/08, at 10:30 a.m., she stated that the resident was being serviced by the beautician on 10/16/08, in the morning. At approximately 12 noon the Certified Nursing Assistant noted a reddened area on the head, ears and back of neck. The resident was assessed by the R.N. Supervisor. The physician was notified and the patient was transferred to the acute hospital for evaluation and treatment. During further interview with the Director of Nursing, she stated that according to the beautician the resident was put under the hair dryer hood. The resident removed the towel and did not stay still under the hair dryer hood. The resident moved her head while under the hair dryer hood. The resident was transferred on 10/16/08, to the acute hospital for an evaluation and returned to the facility with the diagnoses of burns to head, neck and ear. The resident returned to the facility on the same day with discharge instructions for burn care. A review of the interview record for Employee 1, dated October 17, 2008, indicated that Family Member 1 ordered to have Resident 1?s hair done every other week, but when Employee 1 informed the family member that she did not know how to work with African American hair, Family member 1 insisted that she knew how to work with her mother?s type of hair.Family Member 1 then taught Employee 1 how to put the rollers in Resident 1?s hair. On October 16, 2008, Employee 1 covered Resident 1?s head with towels, but the resident removed the towels from her head and got burned with the hair dryer on her forehead and the back of her head. The patient was resistive and would not stay under the hairdryer.However, during an interview with Employee 1 on April 16, 2012, she stated that she had worked for the facility for 29 years and has had 30 years of experience working with hair. However, she doesn?t do black hair (African American hair), had no experience with African American hair and the facility did not offer hair services for black hair. She further stated that she was honest with Family Member 1 and told her that Black people need special people to work on their hair-type, but Family Member 1 insisted for her to do Resident 1?s hair because she had surgery on her arm.Employee 1 further stated that she would only do Resident 1?s hair with permission and the daughter was present. She further stated that while Resident 1 was under the hooded hair dryer, which was an old hair dryer, she was very hyper and moved around a lot, lifting her arms and hands, which was her normal behavior. The control of the heat was around Resident 1?s face and the side of her ear and she never realized that Resident 1 had moved the temperature setting. At the time Resident 1 was under the hooded hair dryer, Employee 1 was applying a permanent on another resident and there were four other residents? being serviced in the beauty shop. When asked how long Resident 1 was under the hooded hair dryer, Employee 1 stated Resident 1 was under the hair dryer for ?40 minutes.? Additionally, a written statement by Employee 1, dated April 19, 2012, indicated that after about three or four times observing Family Member 1 shampoo and setting Resident 1?s hair, she requested that Family Member 1 start doing Resident 1?s hair because her mother had Alzheimer?s and that Family Member 1 had the patience to handle Resident 1. Employee 1 further stated that Family Member 1 stated doing Resident 1?s hair was aggravating her carpel tunnel and the surgery she had on her hands. During the week of the incident, she ran into Family Member 1 who asked her to do Resident 1?s hair on Thursday. Family Member 1 gave her instructions to have her mother taken to the Salon, and start shampooing and setting her mother?s hair. She requested that she put her under the hair dryer on medium/high setting to ensure that her mother?s hair dries completely. She explained to Family Member 1 that she did not use hot setting for the clients and that it was common practice to use a cool setting on the hair dryers. Family Member 1 then stated that she would stop by later that day while her mother was at the Salon. She started working on Resident 1 expecting that Family member 1 would show up at any given time. At this time Resident 1 was very agitated and restless and assumed that her behavior was due to the fact that the patient had Alzheimer?s. She waited as long as she possibly could for Family member 1 to show up to the Salon but she never did show up. After shampooing and setting Resident 1?s hair, she then put her under the dryer. Resident 1 was very restless and constantly moving and lifting her arms. During her restlessness, Employee 1 stated that she believed that Resident 1 must have accidentally moved the temperature of the dryer, up to a hotter setting because the temperature control was at her eye level, on the side of her head. That afternoon, the daughter finally showed up to visit her mom. It was then that Family Member 1 claimed that Resident 1 had been burned and denied that she had requested her mom?s hair to be done at the Salon that day.According to the Acute Hospital Emergency Room record dated October 16, 2008, Family Member 1 stated that when she went to the facility around 2 p.m. she found that Resident 1 was burned all over her head. At 10 a.m. that morning the resident was placed under the hair dryer and she got burned and it was the third time the resident had been burned. She stated that she told the staff at the nursing home not to do her hair unless she was actually there to ensure that she did not get burned. She further stated that Resident 1 was unable to communicate, and so the resident could be having pain and not be able to tell the attending staff that she was in pain from burning so that she could have been quickly removed from the hooded hair dryer. The Emergency report also indicated that the resident?s head had some redness mostly first degree burns, scattered about in her scalp, the top of her auricles (Ears) and at the back of her neck.Review of safety instructions warning for the hooded dryer revealed that close supervision was necessary when the appliance was used by or near children or invalids. The elderly and children are more likely to sustain burns because they may have a delayed reaction to exposure to hot substances or chemicals. The elderly may suffer from memory problems with advancing age and be more at risk for burns (Retrieved from http://www.virtualmedicalcentre.com/diseases.asp?did=864&title=Burns) Hair dryers have been known to reach up to 225 degrees when turned on to the highest setting. For this reason, they can easily cause burns to the skin when touching exposed parts of the neck and scalp. Retrieved from: Damage Caused by Hair Dryers/eHow.com http://www.ehow.com/about_6323619_damage-caused-hair-dryers.html#ixzz1sbcuBrJ8 Physical and cognitive deficits that frequently accompany the aging process increase the risk for fire injury. Reduced touch sensation and slow response time can diminish an older adult's ability to sense a burn when it happens. Retrieved from http://www.seniorssuperstores.com/pages/ELDERLYBURNS.html The facility failed to ensure Resident 1 received adequate supervision to prevent injury by failing to: 1. Follow and apply the electric hooded hairdryer safety instructions that indicated that close supervision be provided to an invalid resident (Resident 1) while under the hooded hair dryer.2. Utilize an alternative means to dry the hair of Resident 1, who was incapable of communicating her safety needs and was constantly moving and thrashing about while seated under the hooded hair dryer.3. Develop a written care plan that contained interventions that addressed the risk factors associated with the use of an electric hooded hairdryer and those residents having fragile skin such as Resident 1.4. Follow the established and agreed upon plan between Employee 1 and Family Member 1 that beauty salon services would be provided to Resident 1 only when Family Member 1 was present to assist because Employee 1 was not experienced in providing hair care services for African-American hair-type. 5. Ensure Resident 1 who was constantly moving around thrashing about while under the hooded dryer, was not left under the under the dryer for 45 minutes.These violations had a direct relationship to the health, safety and security of patients. |
| 950000085 |
SANTA ANITA CONVALESCENT HOSPITAL |
950009616 |
B |
21-Nov-12 |
H9G411 |
5351 |
Health & Safety-1418.91(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. On August 30, 2011, the Department received a written report from the Department of Justice alleging that the facility had failed to report an incident of alleged abuse which occurred at the facility involving Patient A. On August 31, 2011, at 8:55 a.m., an unannounced visit was made to the facility to investigate the complaint and to investigate why the incidents of alleged abuse had not been reported to the Department. Based on interview and record review, the facility failed to notify the Department immediately or within 24 hours of Patient A?s allegation that she was physically abused when a staff member squeezed both of her feet very hard and when she screamed in pain the staff member squeezed her feet harder. A review of Patient A?s medical record revealed that she was a 78 year old female that was admitted to the facility on May 6, 2011, with diagnoses that included disturbance in the blood supply to the brain), anxiety disorder (abnormal and pathological fear and anxiety), and dementia (a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging).The Minimum Data Set (a standardized assessment tool), dated May 17, 2011, indicated that Patient A had memory problems, was moderately impaired in cognitive skills for daily decision making, sometimes made herself-understood, sometimes was able to understand others, spoke clearly, and was totally dependent on others for all activities of daily living. A review of the written letter from the Department of Justice received on August 30, 2011, and dated, August 26, 2011, indicated that on August 22, 2011 (Monday), Family Member 1 reported to the facility that Patient A reported to her daughter that on August 19, 2011, (Friday) a female Hispanic heavy-set staff member squeezed her feet very hard and when Patient A screamed in pain, the staff member squeezed both feet harder than the first time. Patient A did not know the name of the staff member.On August 31, 2011, at 9:05 a.m., an interview was conducted with Staff 1 regarding Patient A?s allegations of physical abuse. Staff 1 stated as soon as he was informed of the allegation, he conducted an investigation and determined that the incident did not occur. Staff 1 stated that he felt that since this alleged abuse did not occur, the facility did not need to report it to the Department. On August 31, 2011, at 9:46 a.m., an attempt was made to interview Patient A. The patient could only remember that the staff had squeezed her feet, but she could not remember any other details. On November 29, 2011, at 2:05 p.m., an interview was conducted with Staff 2 regarding the alleged abuse. Staff 2 stated that sometime in August 2011, the patient?s daughter reported to her that Patient A had complained that an unidentified staff squeezed her feet very hard. Staff 2 reported this allegation to Staff 3, who then reported the allegation to Staff 1.On November 29, 2011, at 2:55 p.m., an interview was conducted with Staff 3 regarding the alleged abuse. Staff 3 stated she was informed by Staff 2 that Patient A complained that an unidentified staff squeezed her feet hard. Staff 3 then reported this alleged physical abuse to Staff 1.According to Patient A?s medical record and the staff interviews, on August 26, 2011, Patient A?s daughter informed Staff 2 that Patient A said someone had entered the patient?s room and squeezed the patient?s feet very hard. Staff 2 informed Staff 3 of the patient?s allegation. Staff 3 interviewed Patient A who recalled the incident, but could not recall who had squeezed her feet. Staff 3 informed Staff 1, who conducted an investigation and determined that no abuse occurred to Patient A. Staff 1 informed Staff 3 and Staff 4 of the conclusion of the investigation and all three staff agreed, that because there was no abuse, this allegation did not need to be reported to this Department and therefore, was not reported. On November 29, 2011, at 3:30 p.m., a review of the facility?s abuse policy and procedure stated, ?The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations.? It also stated, ?Should the investigation reveal that a false report was made/filed, the investigation will cease. Residents, family members, ombudsman, state agencies, etc., will be notified of the findings.? On November 29, 2011, at 4:15 p.m., a second interview was conducted with Staff 1 regarding Patient A?s abuse allegation, Staff 1 stated that ?The facility did not report the alleged abuse, to the Department because Patient A was not actually abused. The facility failed to notify the Department immediately or within 24 hours of Patient A?s allegation that she was physically abused when a staff member squeezed both of her feet very hard and when she screamed in pain the staff member squeezed her feet harder.This violation had a direct relationship to the health, safety or security of patients. |
| 950000085 |
SANTA ANITA CONVALESCENT HOSPITAL |
950009824 |
A |
26-Apr-13 |
EZF611 |
6123 |
F- 309 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Based on interview, and record review, the facility failed to ensure that Resident 20 who had a history of cardiovascular accident (CVA), or stroke (the death of some brain cells due to lack of oxygen) was provided with an anticoagulant medication, that was prescribed by the physician and was necessary to prevent blood clots from forming for a total of 24 days. These failures had the substantial probability to result in a condition that could cause physical harm to Resident 20.On February 12, 2013, at 2:40 p.m., a review of the skilled nursing facility (SNF) admission record for Resident 20, indicated the resident was a 70 year-old female who was originally admitted to the facility on October 16, 2012 and re-admitted on January 20, 2013. The resident?s diagnoses included CVA, diabetes (high blood sugar), and coronary artery disease (CAD/the major blood vessels that supply your heart with blood, become damaged or diseased as a result of the accumulation of plaques that are sometimes made up of fat). On February 12, 2013, during a review of the clinical record for Resident 20, the plan of care for CVA, dated October 17, 2012, indicated under staff?s approach; to provide medications as ordered. The latest Minimum Data Set (MDS), a standardized assessment and care planning tool, dated February 7, 2013, indicated Resident 20 sometimes had the ability to make herself understood and understand others, and required extensive to total assistance for activities of daily living, such as dressing and eating. The MDS indicated the resident had not received an anticoagulant medication in the last 7 days.A review of the SNF?s clinical record for Resident 20, on February 12, 2013, at 2:40 p.m., indicated the resident was taking Plavix (anticoagulant medication) 75 milligram (mg) daily from October 18, 2012 to January 17, 2013.According to the SNF records, on January 17, 2013, the resident was admitted to a general acute care hospital (GACH) for encephalopathy (brain disease, damage, or malfunction) and atrial fibrillation (irregular heart beat) with troponin (proteins release when the heart muscle has been damaged, such as in a heart attack) elevated at 0.310nanograms per milliliter (ng.ml) with a reference range of 0.000-0.050 ng/ml. During this hospital admission the resident?s primary physician, who was the primary physician at both the SNF and the GACH, changed the resident?s anticoagulant medication from Plavix to Xarelto (which is also an anticoagulant).Resident 20 was readmitted to the SNF on January 20, 2013 with a discharge report from the GACH, dated January 20, 2013, indicating for the resident to continue taking Xarelto 15 mg daily. The resident was subsequently transferred back to the GACH on January 27, 2013, and was readmitted back to the SNF on January 28, 2013. The discharge summary from the GACH, dated January 28, 2013, indicated the resident was to continue taking Xarelto 15 mg daily. However, a review of the SNF?s records for January 28, 2013, did not indicate the anticoagulant, Xarelto, for CVA prophylaxis, was transcribed to the Medication Administration Record (MAR). The resident?s re-admission orders for January 20, 2013 and January 28, 2013, did not include Xarelto and was not transcribed on the MARs, to help reduce the risk of further CVAs.Although the physician?s progress note, dated January 31, 2013, indicated Resident 20 was taking an anticoagulant medication due to atrial fibrillation (an irregular and often rapid heart rhythm that can increase the risk for strokes), there was no evidence the resident was administered Xarelto 15 mg for 24 days, as prescribed by the physician from January 20, 2013 to January 27, 2013 (first readmission) and from January 28, 2013 to February 12, 2013, (the second readmission). Xarelto 15 mg daily was not given to Resident 20 until after the physician was notified on February 12, 2012, by the charge nurse once the surveyor had identified the concern of the resident not being receiving Xarelto. During an interview with the charge nurse for Unit 200, on February 12, 2012, at 3:24 PM, he stated that based on the GACH?s discharge report, Resident 20 should have been receiving an anticoagulant medication. The charge nurse was unable to find documentation that Xarelto 15 mg daily, prescribed by the resident?s primary physician, had been transcribed upon readmission. On the same day, after the surveyor asked the charge nurse about the anticoagulant medication, the charge nurse called Resident 20's primary physician to notify him that the resident had not received Xarelto 15 mg daily for a total of 24 days. The physician ordered Xarelto15 mg daily and a platelet count (platelets help the blood clot) for the resident. The platelet count was at 257 x 103/ microliter (uL), with a reference range of 140-440 x 103 /uL. According to American Heart Association, anticoagulants are more effective in decreasing the chances of another stroke for patients that have a history of a stroke and atrial fibrillation (AF) because they prevent the formation of clots in the heart. In AF patients the heart?s atria (the heart?s pumping chambers) quivers instead of beat. As a result, not all of the blood is pumped out of the heart, allowing pools to collect in the heart chamber, where clots may form and cause a strokehttp://www.strokeassociation.org/STROKEORG/LifeAfterStroke/HealthyLivingAfterStroke/ManagingMedicines/Anti-Clotting-Agents-Explained_UCM_310452_Article.jsp) The facility failed to ensure that Resident 20, who had a history of CVA, was provided with an anticoagulant as prescribed by the physician, which was a necessary medication to prevent blood clots from forming for a total of 24 days. The above violation presented a substantial probability that serious physical harm would result to Resident 20. |
| 970000077 |
South Pasadena Care Center |
950009850 |
B |
22-Apr-13 |
4JL511 |
4228 |
F206 ? 483.12(b)(3) A nursing facility must establish and follow a written policy under which a resident whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services. On 1/16/13, at 1 p.m., an unannounced visit was made to the facility to conduct a Complaint investigation. Based on interview and record review, the facility (SNF) failed to follow its written policy to readmit Resident A immediately upon the first availability of a semi-private room. Findings: A review of the admission information record indicated Resident A was admitted to the facility on 6/6/12. The resident's diagnoses included: bronchitis, chest pain, chronic pain, and depressive disorder. The most recent MDS (Minimum Data Set) assessment dated 10/29/12 indicated Resident A was assessed as being oriented with no short- and long-term memory impairment and was able to verbalize her needs appropriately. Additionally, the resident required limited assistance to perform all aspects of daily living. The Face Sheet?s billing information indicated the resident had Medicare and Medicaid insurances. On 1/2/13, the resident was transferred to the acute hospital for evaluation regarding her complaints of pain to the head, neck and back. After 8 days at the acute hospital, the acute hospital physician wrote an order dated 1/10/13 to discharge the resident back to the skilled nursing facility when a bed is available. However, as of 1/16/13 (6 days after the discharge order), the resident remained at the acute hospital. An unannounced visit was made to the SNF on 1/16/13 at 1 p.m. During an interview with the Administrator, he stated that they will not readmit the resident; one reason was not having paid her share of cost of about $4000. Additionally, the Administrator indicated that the facility cannot provide the adequate care that the resident demanded and needed. However, there was no documented evidence that any of the skilled nursing facility?s staff assessed the resident?s demands and needs while at the acute hospital. Hospital records revealed no evidence that the resident required special care or treatment that the skilled nursing facility would not be able to provide. On 1/16/13, at 2:25 p.m., an onsite visit was made to the acute hospital. During an interview, the resident stated that she had nowhere else to go but back to the SNF facility. However, the facility was refusing to take her back. She verbalized her frustration and anger towards the facility for not readmitting her. During an interview with the acute hospital?s discharge planner on 1/16/13 at 2:39 p.m., she stated that she called the SNF ?last week? but she was told there was no available bed for the resident. Therefore, the resident remained in the acute hospital, despite the discharge order since 1/10/13. A review of the facility?s census for the following dates 1/10/13, 1/11/13, 1/12/13, 1/13/13, 1/14/13, 1/15/13 and 1/16/13 revealed there were available beds. However, the facility chose to not readmit the resident. A review of the facility?s policy and procedures, Standard Admission Agreement, revised September 1, 2012, revealed that it was in the verbatim of the regulation, ?A nursing facility must establish and follow a written policy under which a resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident (i) Requires the services provided by the facility; and (ii) Is eligible for Medicaid nursing facility services.? The facility failed to follow its written policy to readmit residents immediately upon the first availability of a semi-private room. The resident required the services provided by the facility, and was eligible for Medicaid nursing facility services. This violation had a direct relationship to the physical, mental, and psychosocial well-being of Resident A. |
| 950000061 |
Sunny View Care Center |
950009866 |
B |
30-Apr-13 |
1BSG11 |
6620 |
F223 ? Resident Abuse. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. On 7/6/10, at 1:55 p.m., an unannounced visit was made to the facility to investigate an entity-reported incident regarding an allegation that Staff 1 hit Resident A on the head. Based on interview and record review, the facility's staff failed to ensure that Resident A was not physically and verbally abused by Staff 1. Staff 1 hit Resident A on the head with the call light and yelled and cursed at her. According to the Admission Record, Resident A was a 101-year-old female who was readmitted to the facility on 2/4/02, with diagnoses that included dementia (loss of cognitive ability) hypertension (high blood pressure) and cerebro-vascular accident (stroke). The Minimum Data Set (a standardized assessment tool of the patient's status) dated 3/31/10 indicated the resident had short- and long-term memory problems with severely impaired daily decision-making skills (never/rarely made decisions). The MDS assessment also indicated that the resident was totally dependent on staff to perform activities such as transfers, dressing, eating and personal hygiene. During an interview on 7/12/10, at 10:10 a.m., Staff 2 stated that on 6/11/10, at approximately, 7 a.m., she was walking with Staff 3 in the hallway to attend to a resident, when she and Staff 3 saw Staff 1 in the resident?s room hit Resident A on the top of the head with the call light device (a mechanical device used by the resident to call for a nurse. It was a hospital type with the TV controls and call light button) and yelled ?Callate, cabrona!? (Spanish for ?Shut up, bitch!?). She stated that she and Staff 3 continued to walk and, then, they discussed what they saw and heard. Staff 3 then reported the abuse to the night shift nursing supervisor after their shift ended (both Staff 2 and Staff 3 worked the 11 p.m., to 7 a.m., shift). Staff 2 has worked in the facility for 4 years and Staff 3 has worked one year. During an interview on 7/12/10, at 10:45 a.m., Staff 3 stated that on 6/11/10, at around 7 a.m., she and Staff 2 were walking in the hallway to attend to a resident when she and Staff 2 saw Staff 1 hit Resident A on the head with the call light device and yelled ?Callate, cabrona!? Staff 3 stated that she and Staff 2 discussed what they had just witnessed and heard, and then she reported it to the night shift nursing supervisor. Staff 3 said that she was shocked and nervous from the abuse that she witnessed and she became tearful during this interview.The facility?s Investigation Report dated 6/11/10, indicated that, ?Around 8:50 a.m., nursing administration went and assessed the resident who was lying in bed and it was noted that there was a small reddened area with a very small open area on top of the residents head closer to her forehead.?The investigation report further stated that at around 9:45 a.m., on 6/11/10, the nursing administration reassessed the resident. The report indicated, ?When the area of concern (small open area on top of the resident?s head) was touched gently the resident reacted by attempting to strike out. When other areas of the resident?s head were assessed the resident cooperated, but when the area of concern was touched again the resident again attempted to strike out.? According to the skin assessment the resident had a small abrasion. A review of the Interdisciplinary Notes dated 6/11/10, at 2:45 p.m., revealed that the resident was unable to state the cause of the injury to her head. It was the first time this open area was observed by staff. A physician?s order was obtained on 6/11/10, to cleanse the abrasion with normal saline and to apply triple antibiotic ointment daily for 7 days. During an interview with the resident on 7/6/10, at 3:50 p.m., she was very confused and was unable to engage in any conversation. She was observed repeatedly yelling ?Hola? (Spanish for ?hello?). There was no more open area observed on the head. A review of Staff 1?s employee files revealed that she has been a Licensed Vocational Nurse (LVN) since April 1983. She has been an employee of this facility since 4/3/84. Her last abuse training was on 8/29/09. Her last performance evaluation was dated 6/8/10. The performance evaluation revealed the following:1. Interpersonal Skills (Needs Improvement). Staff 1 ?needs to communicate more efficiently with co-workers in order to be a better team player. She needs to communicate respectfully to others e.g. there was an on-going lack of communication among charge nurses receiving change of shift report. A meeting was held in order for each licensed nurse including (Staff 1) to express their concerns and how to improve their relationship. All members are committed to improving how to communicate change of shift report with each other.?2. Cooperation (Needs Improvement). ?Cooperation is needed with (Staff 1) and the in-coming license nurses in giving change of shift report. This needs to be done harmoniously to ensure that tasks are completed.? During an interview with Staff 1 on 11/17/10, at 8:05 a.m., she denied hitting and being verbally abusive to the resident. She stated that she did not see the resident around 7 a.m. as Staff 2 and Staff 3 had claimed.A review of the Corrective Action Notice, dated 6/11/10, revealed the facility suspended Staff 1 pending the facility?s investigation of the alleged abuse. During an interview on 9/13/10, at 2:15 p.m., Staff 4 stated that the facility substantiated the abuse allegation as a result of its thorough investigation and had terminated Staff 1.The facility?s policy and procedures on abuse, dated 4/8/09, indicated, ?TEHC (The Episcopal Home Communities) will not condone any form of resident abuse and will continually monitor our facility?s policies, procedures, training programs, systems, etc., to assist in preventing resident abuse.? The facility?s policy and procedures defined abuse as ?The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse may also include unauthorized financial access or transactions with resident monies.? The facility?s staff failed to ensure that residents were not physically and verbally abused. These violations had a direct relationship to the health, safety or security of Resident A. |
| 970000077 |
South Pasadena Care Center |
950009988 |
B |
01-Jul-13 |
LVX921 |
3537 |
On January 29, 2013, at 7:30 a.m., during an annual recertification visit observations to confirm the required facility postings were done. Based on observation, and interview, the facility failed to comply with a California Health & Safety Code requirement by: 1. Failing to post complete information regarding their most current overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS). Findings: During an initial tour of the facility on January 23, 2013, at 7:30 a.m., the evaluator observed the posting of the facility's most current overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS) by the nursing station at the front lobby entrance. The posting indicated that CMS rated the facility three (3) out of five (5) stars. However, the following language which is required by California Health & Safety Code section 1418.21 was not included: "This facility is reviewed annually and has been licensed by the State of California and certified by the federal Centers for Medicare and Medicaid Services (CMS). CMS rates facilities that are certified to accept Medicare or Medicaid. CMS gave the above rating to this facility. A detailed explanation of this rating is maintained at this facility and will be made available upon request. This information can also be accessed online at the Nursing Home Compare Internet Web site at http://www.medicare.gov/NHcompare. Like any information, the Five-Star Quality Rating System has strengths and limits. The criteria upon which the rating is determined may not represent all of the aspects of care that may be important to you. You are encouraged to discuss the rating with facility staff. The Five-Star Quality Rating System was created to help consumers, their families, and caregivers compare nursing homes more easily and help identify areas about which you may want to ask questions. Nursing home ratings are assigned based on ratings given to health inspections, staffing, and quality measures. Some areas are assigned a greater weight than other areas. These ratings are combined to calculate the overall rating posted here. State licensing information on skilled nursing facilities is available on the State Department of Public Health's Internet Web site at: www.cdph.ca.gov, under Programs, Licensing and Certification, Health Facilities Consumer Information System." During an interview with the administrator on January 29, 2013, at 3:53 p.m., he stated he was not aware of the requirement to post the additional required language that comes after the posting of the star rating. He then instructed his staff to make the necessary corrections and posted the corrections at 4:00 p.m. The failure of the facility to post their federal rating deprives the consumer of available information to assist in making an informed choice whether to admit a resident to the facility. The facility failed to comply with a California Health & Safety Code requirement by: 1. Failing to post complete information regarding their most current overall facility rating information determined by the federal Centers for Medicare and Medicaid Services (CMS). Failure of the facility to post the facility?s rating information (Five-Star Quality Rating) determined by the Centers for Medicare and Medicaid Services (CMS) in the required areas for review by the residents, staff, and the public, constitutes a class B violation, as defined in subdivision (e) of Section 1424. |
| 970000077 |
South Pasadena Care Center |
950010023 |
B |
24-Jul-13 |
BO2G11 |
13046 |
F 329 ? 483.25 (l) 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. F 157- 483.10 (b) (11) Notification of Changes 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). On March 09, 2010, at 8:30 a.m., an unannounced visit was made to the facility to investigate allegations Resident A reportedly did not receive proper medical attention and help from the staff at the skilled nursing facility (SNF). The resident was transferred to an acute hospital on February 24, 2010, and was diagnosed with Dilantin toxicity. Based on interview and record review, the facility failed to ensure Resident A was adequately monitored for the use of Dilantin, a medication used to treat seizures by failing to: 1. Promptly consult with the attending physician, when Resident A?s Dilantin was used in excessive dose (above the usual maximum daily dose) and to immediately notifying the attending physician when the resident reported to the staff, that he was experiencing loss of coordination indicating that the resident had possible Dilantin overdose/toxicity that required physician intervention 2. Develop a care plan for the use of Dilantin, to include a method of monitoring for normal therapeutic laboratory blood levels, of monitoring for signs and symptoms of toxicity and how to intervene in the event that the resident developed signs and symptoms of Dilantin toxicity.As a result Resident A developed an inability to stand, (a sign of ataxia), and slurred speech, to such an extent the resident required evaluation and treatment at an acute hospital emergency room where he was identified with Dilantin toxicity, a condition that can lead to coma.According to the acute hospital history and physical dated February 12, 2010, Resident A was originally admitted to an acute hospital from home with diagnoses including status epilepticus (a potentially life-threatening condition- an abnormally prolonged seizure), seizure disorder (convulsions), and bipolar disorder (a mental illness). On February 13, 2010, at 7:50 a.m., while at the acute facility, the resident?s Dilantin laboratory blood level was measured at 15.8 micrograms per milliliter (ug/ml) which was within the reference range of 10 ug/ml to 20 ug/ml. The acute facility Medication Reconciliation Report dated February 14, 2010, indicated Resident A was to continue taking Dilantin 100 milligrams (mg) 4 capsules, (400 mg each dose, a total of 1, 200 mg. a day ) three times a day. The resident was treated at the acute hospital until February 15, 2010. The transfer record revealed the resident was sent to the SNF on February 15, 2010, with primary diagnoses including poorly controlled seizures.Resident A was 42 year old male, who was admitted to the SNF on February 15, 2010, from the acute hospital, with diagnoses including status epilepticus (seizures) and bipolar disorder. The admission orders dated February 15, 2010, indicated to administer Dilantin 400 milligrams by mouth three times a day.The Minimum Data Set (MDS, a comprehensive assessment and care planning tool) dated February 22, 2010, indicated the resident was moderately impaired in cognitive (mental) skills, had short term memory problems, could ambulate in his room with set up help only, could make himself understood, had the ability to understand others and had seizures.The care plan dated February 15, 2010, titled ?Seizure Disorder? indicated the following approaches would be provided for the resident: 1. Labs (laboratory) as ordered 2. Report the results to the physician 3. Monitor for toxic signs of medication (i.e. slurred speech, ataxia, lethargy (sleepy), and dizziness.The care plan did not address the use of Dilantin, to include a method of monitoring for normal therapeutic laboratory blood levels, for monitoring for signs and symptoms of toxicity or how to intervene in the event that the resident developed signs and symptoms of Dilantin toxicity.According to the Davis?s Drug Guide for Nurses, Seventh Edition and Mosby?s Nursing Drug Reference, 23rd Edition, 2010. The usual adult maximum dose for maintenance of Dilantin is 600 milligrams (mg) per day. Toxic level is 30 ug/ml to 50 ug/ml. The nursing implications in the use of Dilantin (phenytoin) include assessment of toxicity and overdose and serum phenytoin levels should be routinely monitored. The progressive signs and symptoms of phenytoin toxicity include, ataxia (uncoordinated movements such as trouble walking) and slurred speech.The medication administration record (MAR) dated February 15, 2010, at 5 p.m. to February 24, 2010, at 1 p.m. indicated that Dilantin and other medications were administered as the physician ordered.There was no documented evidence that the physician and the pharmacist were consulted regarding the dosage of the Dilantin ordered of 1, 200 mg per day as being excessive to the recommended maximum daily dosage. The licensed nurses? notes of February 22, 2010, at 7 a.m., indicated the resident looks very sleepy, could not stand, (a sign of ataxia), and that the resident had a lot of seizure disorder medications.However, there was no documented evidence the attending physician was notified of the resident?s change of condition. Furthermore, the licensed nurses notes dated February 23, 2010, at 10:30 p.m. indicated the resident reported to Licensed Nurse 3 that he was ?over drugged? and that he "cannot stand up.? However, there was no documented evidence the attending physician was notified of the resident?s complaints. A review of the physician?s orders indicated a Dilantin blood level test was ordered on February 24, 2010, at 8:30 a.m. which was over 49 hours after the resident?s initial signs of possible Dilantin toxicity as documented in the licensed nurses? notes and over nine (9) hours after the resident voiced his concerns to Licensed Nurse 3 of possible drug overdose / toxicity.During an interview with Licensed Staff 1 on March 3, 2010, at 3 p.m., he stated the resident had developed an unsteady gait on an unspecified date, to such an extent that Resident A required the use of a wheelchair.There was no documented evidence on the MAR of February 15, 2010, through February 24, 2010, that the resident was monitored for signs of slurred speech, or ataxia could indicate the resident had possible drug overdose/toxicity from the use of Dilantin.On February 24, 2010, at 8:30 a.m., the physician ordered Dilantin level to be done on the same day. However, this was not done, and the resident was transferred to the acute hospital. The licensed nurse?s notes dated February 24, 2010, at 9:45 a.m., the resident requested to be sent to the hospital. Then at 10 a.m., Resident A was transferred to an acute hospital.According to the Paramedic?s Incident Record dated February 24, 2010, at an unspecified time, Resident A complained of not being able to stand due to loss of coordination from (unspecified) medications given to him by the staff. The emergency room physician evaluation dated February 24, 2010, at an unspecified time, indicated Resident A complained of having difficulty in coordinating his legs and visual disturbances. The physician evaluation indicated Resident A had ataxia. The resident?s Dilantin level result was measured at 32 (ug/ml, a reading that is considered high, in comparison to the normal reference range of 10 ug/ml to 20 ug/ml when admitted to the acute hospital for Dilantin Toxicity. The usual adult maximum dose for maintenance of Dilantin is 600 milligrams (mg) per day. The toxic level is 30 ?g/ml to 50 ?g/ml. Mosby?s Nursing Drug Reference, 23rd Edition, 2010. The acute hospital neurology consultation assessment dated February 24, 2010, at an unspecified time, indicated the resident had hesitant speech which was slurred and was secondary to his Dilantin Toxicity, as well as ataxia and vertical and horizontal nystagmus (motions of the eyes).Dilantin (a medicine used to treat seizures) overdose (toxicity) occurs when someone takes too much of this medicine, with moderate overdose ? the patient has uncoordinated movements such as trouble walking straight or pointing to objects and with severe overdose the patient has slurring speech. It may take 3 - 5 days for the patient to recover. www.nlm.nih.gov/medlineplus/ency/article/002632.htm. Additionally, the resident was evaluated and followed by the neurologist (is a medical doctor who specializes in the study, diagnosis and treatment of injury and diseases of the nervous system), a psychiatrist (is a medical doctor who specializes in preventing, diagnosing, and treating mental illness) and an internist (is a doctor who is trained to treat diseases inside the body). The resident also received physical therapy services due to problems with coordination. A computerized tomography (CT- uses X-rays to make detailed pictures of structures inside the body) scan of the head was taken which showed no evidence of hemorrhage and acute lesion.Further review of the acute hospital records indicated the resident was hospitalized for six (6) days from February 24, 2010, through March 01, 2010. Resident A was discharged home in stable condition with family support and orders for home physical therapy, home visiting nurse care and out?patient medical follow-up. The physician ordered the following discharge medications: 1. Seroquel 200 mg every night 2. Zoloft 100 mg daily3. Desyrel 100 mg every night 4. Neurontin 300 mg twice a day 5. Depakote 250 at bedtime 6. Depakote 500 mg two times a day 7. Lamictal 100 mg every day According to the facility?s policy and procedure dated January 2010, titled ?Dilantin?, ?It is the policy of the facility to safely administer this medication to the resident. Dosage adjustments and serum level monitoring may be necessary when on the therapy.?The facility?s policy and procedure titled ?Change of Condition Reporting? revised December 10, 2009, indicated ?It is the policy of the facility that all changes in resident condition will be communicated to the physician. Licensed nurse will inform the primary physician (alternate physician or Medical Director) of resident?s status as soon as possible before, during or after the change of condition. Any sudden or serious change in a resident?s condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for the physician visit promptly and or acute care evaluation. All symptoms and unusual signs will be communicated to the physician promptly.?The facility failed to ensure Resident A was monitored for the use of Dilantin, a medication used to treat seizures by failing to: 1. Promptly consult with the attending physician when Resident A?s Dilantin was used in excessive dose (above the usual maximum daily dose).2. Develop a care plan for the use of Dilantin, to include a method of monitoring for normal therapeutic laboratory blood levels, of monitoring for signs and symptoms of toxicity and how to intervene in the event that the resident developed signs and symptoms of Dilantin toxicity.3. Immediately notifying the attending physician when the resident reported to the staff, that he was experiencing loss of coordination indicative the resident had possible Dilantin overdose / toxicity that required physician intervention. As a result Resident A developed inability to stand, a sign of ataxia, and slurred speech, to such an extent that the resident required evaluation and treatment at an acute hospital emergency room where he was identified with Dilantin toxicity, a condition that can lead to coma. The above violations either jointly, separately or in any combination 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 A. |
| 970000167 |
SAINT VINCENT HEALTHCARE |
950010103 |
B |
20-Aug-13 |
KOYV11 |
5889 |
Health & Safety-1418.91 (a) A long term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. On January 31, 2013 at 3:56 p.m., the Department received a report from the facility of a Suspected Dependent Adult/Elder Abuse (SOC 341), which indicated Patient A reported that Patient B had hit her on the left arm after trying to take a bag of chips away from the patient. The incident occurred on January 25, 2013 at 2:30 p.m. On February 22, 2013 at 1:30 p.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding patient abuse. Based on interview and record review the facility failed to:1.Report the incident to the Department within 24 hours.2.Implement the facility?s policies and procedures on patient abuse reporting. A review of Patient A?s, ?Face Sheet?, indicated the patient was admitted to the facility on April 1, 2005, and re-admitted on July 5, 2012. The patient?s diagnoses included Schizophrenia (a group of severe brain disorders in which people interpret reality abnormally and may result in some combination of hallucinations, delusions and disordered thinking and behavior). A review of a quarterly Minimum Data Set (MDS), a standardized assessment and care screening tool, datedJanuary 11, 2013, indicated the patient was able to make herself understood and able to understand others. The patient suffered from delusions as well as manic depression. A review of Patient B?s, ?Face Sheet?, indicated the patient was admitted to the facility on November 28, 2012 and readmitted on January 17, 2013. The patient?s diagnoses included chronic bronchitis (inflammation of the airways in the lungs). An MDS dated December 14, 2012, indicated Patient B was sometimes understood and sometimes able to understand others. The MDs also indicated the patient had delusions. Review of the undated Investigation Report , indicated the director of nursing (DON) met with Patient A on January 29, 2013 (no time indicated). According to the report Patient A claimed she was hit on the left forearm by Patient B when she tried to grab a bag of chips from the patient. The patient sustained three, ?dime-sized purplish, yellowish discoloration?. When the patient was asked by the DON if a nursing staff was aware of the incident, the resident stated, ?Yes?treatment nurse is giving a treatment; he put ointment.? In an interview on February 22, 2013 at 2 p.m., Patient A stated she was in the hallway near the dining room when she had witnessed a patient give a bag of chips to Patient B. Patient A stated, ?I took it upon myself to take away the chips and he did not want to give them up. I knew he wasn?t supposed to eat chips.? According to the patient as she struggled to get the bag of chips, she sustained a bruise on her left arm. The patient also stated the staff was in a meeting that day and there were three nurses on the floor but she did not tell any of them what had happened. During an interview on February 22, 2013 at 2:35 p.m., Staff 2 stated the facility?s policy for resident to resident altercations is to complete an incident report, notify the director of nursing, the administrator, the physician, and the responsible party. If there is any injury then treatment is provided. According to Staff 2, she had been told during morning report, that the patient had not reported the incident to the staff until the day after it happened. In another interview on February 22, 2013 at 3:25 p.m., Staff 4 stated the patient had showed her the bruise on her arm and had stated the bruise was acquired while trying to take something away from another patient. According to Staff 4 the patient stated she had told Staff 5 about the incident over the weekend a day after the incident happened. During a phone interview on February 26, 2013 at 7:27 a.m., Staff 5 (who?s been working in the facility for approximately one year) stated on Saturday January 26, 2013, (one day after the incident) he noticed the resident had some bruising on her forearm.According to Staff 5, the resident had stated she had obtained the bruise while trying to take food from another resident. Staff 5 was asked if he reported the incident to any supervisor he stated, ?I don?t remember.? When asked if he had notified the patient?s physician he stated, ?I don?t remember.? When asked what the facility?s policy is regarding resident to resident altercations Staff 5 stated, ?We have to monitor for skin breakdown.? In an interview on February 26, 2013 at 9:00 a.m., Staff 6 stated the activity director and the patient had told her about the incident on February 29, 2013. According to Staff 6, Staff 5 should have reported the incident when the patient told him what happened on February 26, 2013.A review of the facility?s undated policy, ?Elder/Dependent Adult Abuse?, dated June 30, 2005 and revised May 8, 2013, indicated all staff shall be provided with instruction on facility policy/procedure, mandated reporting procedures, and receive a copy of their obligation to comply with the elder/dependent adult abuse laws upon hire (within 60 days) and annually. According to the policy if an alleged or suspected, ?Physical abuse?, does not result in serious bodily injury then the mandated reporter shall make a written report to the local ombudsman, California Department of Public Health (CDPH) and local law enforcement within 24 hours. The facility failed to implement their abuse policies and procedures by failing to: 1. Report the incident to the Department within 24 hours. 2. Implement the facility?s policies and procedures on patient abuse reporting. These violations had a direct relationship to the health and safety of Patient A. |
| 950000018 |
SIERRA VIEW CARE CENTER |
950010484 |
A |
13-Mar-14 |
YN9111 |
7711 |
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 11/30/10, an unannounced visit was made to the facility to investigate an allegation that Resident A had broken her right hip after falling backward from the wheelchair while in her room.Based on observation, interview and record review, the facility failed to: 1. Implement safety precautions during a transfer as indicated in the plan of care for Resident A who was unable to maintain his balance while standing without physical help. 2. Implement the facility?s policy for resident safety by not leaving Resident A standing on a wet linen sheet on the floor that became a slipping hazard during a transfer.As a result Resident A lost her balance and fell during a transfer resulting in a fractured right hip. A review of the admission face sheet revealed Resident A was a 74 year old female who was admitted to the facility on 6/30/09, with diagnoses that included osteoporosis (a condition that causes bones to become less solid and dense which gradually makes them weaker and more brittle), blindness and low vision of one eye.A review of the comprehensive Minimum Data Set assessment (MDS-a standardized assessment and care planning tool) dated 6/18/10 and the quarterly MDS 9/9/10, indicated Resident A had good short and long term memory recall ability, was able to make herself- understood and understand others, had moderately impaired vision, required limited assistance in ambulation and transfer with one person physical assist, had partial loss of voluntary movement of the foot and was unable to maintain balance while standing without physical help.A review of Resident A?s plan of care dated 9/14/10, indicated the resident was at risk for falls/ fracture due to gait imbalance, cognitive impairment, history of a fall, osteoporosis and right eye blindness due to a cataract . The care plan goal was for Resident A not to have a fracture. The care interventions included avoidance of sudden position changes for Resident A, removal of spills or clutter, to handle the resident gently when moving and to observe safety precautions (unspecified) during care.A review of the licensed nurses? notes indicated on 11/15/10 at 8:20 a.m., Employee 2 had reported to the licensed staff that Resident A was being assisted back to bed from the shower chair when the resident lost her balance and fell on the right side of her body to the floor. The resident had a facial grimace when she complained of pain in the right hip. Resident A was transferred to the acute hospital on 11/15/10 at 9:50 a.m., for evaluation of the right hip.A review of the acute hospital emergency department summary notes dated 11/15/10, indicated Resident A had complained of a right hip pain, in a (pain level) scale of 10/10 (10 being the highest) after a fall from a nursing facility. Resident A was assessed as unable to walk and unable to bear weight. Resident A had an open reduction internal fixation (a surgical procedure to fix a severe bone fracture, or break) of the right hip fracture on 11/17/10, due to a right femoral neck fracture. The resident was readmitted to the skilled nursing facility (SNF) on 11/21/10, after surgery of her right hip.On11/30/10 at 4 p.m., the employee file of Employee 2 was reviewed in the presence of Employee 3. According to the ?Employee Discussion Documentation? dated 11/15/10, Employee 2 stated the resident slid and fell to the floor while being transferred from the shower chair to the bed. Employee 2 stated the floor was dry when the shower blanket (linen) was left on the floor during the transfer. Further review of the aforementioned documentation indicated the facility instructed Employee 2 to ensure the floor is dry before transferring a resident and to ask for assistance when necessary. Employee 2 was unavailable for interview during the investigation. On11/30/10 at 4:05 p.m., Employee 3 stated Employee 2 was terminated on 11/22/10, due to ?Violation of company policy and safety rules.? (unspecified). During an observation on 11/30/10 at 4:20 p.m., Resident A was in bed lying on her back, alert but only speaks Spanish. She had a wound dressing on her right hip. On the same day at 4:25 p.m., she was interviewed in the presence of Employee 1 who acted as the interpreter for the resident. The resident stated Employee 2 brought her back to her room after a shower on an unspecified date (unable to recall date). She stated Employee 2 instructed her to get up from the shower chair and was asked to stand on a wet floor covered with a linen sheet. Resident A stated while she was standing in front of the shower chair, Employee 2 left the room to ?get something?. She stated she then lost her balance when the wet linen sheet she was stepping on slid, and she fell to the floor. She stated she had an unbearable pain in the right side of her leg after she fell. The care plan interventions dated 9/14/10, to observe safety precautions during a transfer were not fully implemented when on 11/15/10 at 8:20 a.m., Employee 2 left Resident A standing in her room without physical assistance, as the resident was unable to maintain balance while standing. Additionally, when Resident A stood without physical assistance on a linen sheet on the floor, the sheet became a hazard, as it slid on the floor, resulting in the resident losing her balance and falling to the floor.During an interview on 11/30/10 at 4:40 p.m., Employee 3 stated a wet floor should be mopped dry and should not be covered with a linen sheet because it is slippery for a resident to step on which could result in a fall or injury.Further review of the medical record indicated Resident A had physical therapy to her right lower extremity after readmission to the SNF on 11/21/10. According to the physical therapy initial evaluation notes dated 11/22/10, Resident A was unable to ambulate and required extensive assistance in transfer with two person physical support. The resident had decreased strength to both lower extremities, decreased range of motion to the right hip, impaired static/dynamic standing balance, decreased coordination/motor control and endurance. The resident received physical therapy from 11/22/10 through 2/28/11.A review of the facility?s undated policy and procedure titled ?Safety and Supervision of Residents? indicated ?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.?The facility failed to: 1. Implement safety precautions during a transfer as indicated in the plan of care for Resident A who was unable to maintain his balance while standing without physical help. 2. Implement the facility?s policy for resident safety by not leaving Resident A standing on a wet linen sheet on the floor that became a slipping hazard during a transfer.As a result Resident A lost her balance and fell during a transfer resulting in a fractured right hip. The facility?s failure to ensure the environment remains as free from accident hazards as is possible; and to ensure the resident received adequate supervision to prevent falls, lead to Resident A?s fall during a transfer that resulted in a fractured right hip. 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. |
| 970000077 |
South Pasadena Care Center |
950011142 |
B |
26-Nov-14 |
519411 |
3338 |
Health & Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. On 7/18/13, at 3:35 p.m., an unannounced complaint visit was conducted to investigate an allegation of resident to resident abuse.The facility failed to report an allegation of resident to resident abuse between Residents 1 and 2. Resident 2 pushed Resident 1 which resulted in Resident 1 sustaining multiple skin tears to the left hand and skin discoloration to the left cheek and left hand.On 7/18/13, at 4:10 p.m., neither of the residents was present in the skilled nursing facility. Resident 1 had a physician order for a seven day bed hold, after a transfer to the acute hospital, since 7/17/13 and Resident 2 had a physician order for a discharge to the acute hospital on 7/13/13.During an interview with Staff 1 on 7/18/13 at 3:45 p.m., he stated he witnessed the altercation between Resident 1 and Resident 2. Staff 1 further stated Resident 2 was complaining of Resident 1's television. When suddenly, Resident 1 heard the conversation and told the RN she was upset because Resident 2 was slamming doors. Resident 1 walked towards Resident 2 and addressed her with a foul name. Resident 2 reacted by pushing Resident 1 and Staff 2 separated both residents. The RN was asked if he reported the incident, he stated he notified the DON and administrator the day of the incident. During an interview with the DON and administrator, on 7/18/13, at 4:10 p.m., when asked if the altercation was reported to the Department, the administrator responded, he sent a letter to the department on 7/15/13, without the report of suspected dependent adult/elder abuse (SOC 341), as required by the State. He further added the incident was reported on Monday 7/15/13 because the incident occurred on a Saturday 7/13/13. The administrator was asked what the facility?s policy for reporting abuse was; he responded the abuse should be reported within 24 hours of the incident. On 5/28/14, at 12 p.m., during an on-site visit at the facility, Resident 1's medical record was reviewed. The admission face sheet indicated the resident was admitted to the facility, on 7/7/13, with diagnoses that included difficulty walking, anxiety disorder (abnormal and pathological fear and anxiety), and depression (mood disorder). The care plans dated 7/13/13 indicated the resident had skin tears on two sites and multiple discolorations to the left hand and, a discoloration to the left cheek. A review of the facility's policy and procedure titled, "Reporting Abuse" dated 2/1/13, indicated the reporting requirements for the facility is to report known physical abuse to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations. Furthermore, a written report shall be made to the California Department of Public Health within 24 hours of the observation, knowledge, or suspicion of the physical abuse. The facility did not follow the policy as indicated. The facility failed to report an alleged abuse of a resident to the Department immediately, or within 24 hours. The violation had a direct relationship to the health, safety and security of residents. |
| 970000077 |
South Pasadena Care Center |
950011289 |
A |
03-Apr-15 |
07IS11 |
11353 |
F323 ? 483.25 (h) Accidents The facility must ensure that- 1) The resident environment remains as free from accident hazards as is possible; and 2) Each resident receives adequate supervision and assistive devices to prevent accidents. On 11/10/14, at 11:15 a.m., an unannounced complaint investigation was initiated regarding Resident 70, who went out on pass from the facility, poured gasoline on herself and lit herself on fire. On 11/10/14, at 11:30 a.m., during the revisit survey the investigation continued and was completed.The facility failed to ensure Resident 70 received adequate supervision to prevent accidents by failing to: 1. Ensure the attending physician conducted an assessment as indicated in its policy and procedure prior to allowing the resident to leave out on pass unaccompanied by a responsible adult.This deficient practice consequently resulted in second and third degree burns over 90% of Resident 70?s body and her death in an acute hospital burn unit the following day. A review of Resident 70's medical records indicated she was a 57 year old female who was originally admitted to the facility, on 11/6/13, and re-admitted to the facility, on 12/26/13, and on 2/10/14, with diagnoses (on each admission) of schizophrenia (A mental disorder of abnormal social behavior, which includes false beliefs, confused thinking, auditory hallucinations, reduced social interaction, and inactivity), psychosis (An abnormal condition of the mind, which involves the loss of reality.), and anxiety disorder (A mental disorder characterized with anxiety of worrying about future events and fear of current events).The pre-admission screening resident review forms, dated 11/6/13, 12/26/13 and 2/10/14, indicated that Resident 70?s primary admitting diagnoses were schizoaffective disorder, bipolar disorder (a mental disorder with elevated mood and periods of depression. Residents with this disorder often make poor decisions with little regard to the consequences and are at risk of suicide and self-harm. The medical records indicated the resident was conserved by a public guardian.According to the minimum data set (a standardized assessment and care planning tool), dated 8/18/14, the resident spoke clearly, made herself understood, able to understand others, needed supervision to limited assistance for activities of daily living, and had current diagnoses of anxiety disorder, depression and schizophrenia.On 8/19/14, a psychiatric progress note indicated Resident 70 was alert and not oriented, and had impaired insight and impaired judgment.On 10/9/14, the behavior care plan for altered behavior related to schizoaffective disorder was updated to include auditory hallucination and talking to self. On 10/9/14, the physician ordered to administer Abilify 10 mg, by mouth, twice a day for schizoaffective disorder manifested by auditory hallucinations (hearing voices) and talking to self. On 10/21/14, 12 days later, the physician wrote an order that the resident "May go out on pass."On this same day, a care plan was also initiated for Out on Pass (OOP) and noted the resident may leave the premises unattended for 2-4 hours per family request. There was no documented evidence that the psychiatrist made a determination that Resident 70 was capable of being on an independent, unsupervised pass.The facility sign out sheet indicated on 11/7/14, at 7:30 a.m., Resident 70 signed herself out on pass (alone) to go out to the library.On 11/10/14, at 12 p.m. an interview was conducted with Gas station attendant #1. He stated that on 11/7/14, his security camera recorded Resident 70 walking across the back parking lot, and 10 minutes later she was naked and walked back across the parking lot. He said she purchased gasoline from Gas Station Attendant #2.An interview was conducted with Gas Station Attendant#2 at 12:30 p. m who confirmed that the resident purchased a gas container and gasoline that morning, and then walked way.A review of the security video disk recording indicated at 8:05 a.m., Resident 70 walked behind Gas station #2, and through the parking area and in-between an enclosed fenced area and a brick fence that separated the gas station and the neighboring restaurant. Resident 70, who was then naked, walked through the parking area, stopped in front of the only parked car and crouched in-between the car and the brick fence. At 8:14 a.m., Resident 70 stood up and calmly walked from this parking area, down the sidewalk and into the next door neighbor's covered driveway. During an interview, on 11/24/14, at 1 p.m. with the Neighbor and his wife , they stated that on 11/7/14 at about 8:30am, they saw the police cars and fire truck at the gas station's parking lot. They walked up to their side of the brick fence and looked over the fence. As they were standing there, they heard a female moaning. Resident 70 stood up from behind the trash cans and said someone was after her. As the resident calmly came out from behind the trash cans, the neighbor's wife saw that Resident 70 was burnt over most of her body and screamed out loud. The policemen heard this, came over to the neighbor's side of the brick fence and saw the resident. Resident 70 saw the policemen and asked for help. One of the policemen retrieved a blanket from their car and as soon as he placed it on the resident, to cover her naked body, Resident 70 screamed in pain. The other policemen called for an ambulance to provide emergency care to the resident. Paramedics arrived, assessed Resident 70, placed her on a gurney and transported the resident to acute hospital #1.On 11/13/14, at 1 p.m. an interview was conducted with police officer 1. He called for an ambulance and the resident was subsequently, transferred to the acute hospital. He further stated the resident had expired. On the same day a review of the police report was conducted.On 11/21/14, at 1:45 p.m. an interview with Resident 70's psychiatrist was conducted regarding the resident's out on pass order. During this interview the psychiatrist stated the licensed nursing staff assess the residents to determine if they are suitable to go out on pass. If the residents have a responsible party, family or conservator, the nursing staff must communicate with this responsible party to obtain their approval for the resident to go out on pass According to the acute hospital # 1 medical record dated 11/7/14, at 8:55 a.m., Resident 70 entered acute hospital #1's emergency room, was assessed and intubated to assist with her breathing (Intubate is the process of inserting a tube into the front of a patient's throat to assist a critically ill patient to breathe with the help of a ventilator.). Acute hospital #1 emergency room staff was not able to provide the proper care for Resident 70 because she had second and third degree burns over 90% of her body. Acute hospital #1 decided to send Resident 70 to Acute hospital #2 because they had a burn unit. Another ambulance transported the resident to acute hospital #2. At 12:50 p.m., the resident was admitted to acute hospital #2's burn unit, was assessed and stabilized. The burn unit nursing staff determined that Resident 70 was burned over 88.5% of her body. Acute hospital #2 contacted Resident 70's sister and was informed of the resident's condition. The sister informed acute hospital #2 that the resident would not want to be kept alive by artificial means. Acute hospital #2 stated they would provide comfort care to allow the sister to visit at Resident 70's bedside.On 11/8/14, at 3:10 a.m., Resident 70 expired while at acute hospital #2.The facility's (undated) out on pass policy and procedure requires an order from the attending physician for a resident to go out on pass. The resident must be accompanied by a responsible adult when leaving the facility unless the physician determines that the resident is capable of being on an independent pass. A responsible person is considered to be a person over 18, can call for medical assistance (if required) and is a family member, friend, facility staff or conservator. It also stated that the attending physician will review the resident's ability to participate in activities outside of the facility, while taking into consideration the resident's decision-making capacity, physical disabilities, and other characteristics. If the physician determines that the resident may participate in activities outside the facility, the attending physician will write an out on pass order on the physician order sheet. On 11/20/14, at 3:45 p.m., an interview was conducted with Resident 70's physician regarding the resident's out on pass order. During this interview, the physician stated that the last time he saw the resident was at the end of October and he was not aware of her death. The physician stated that he did not remember writing an out on pass order for Resident 70. The physician did say that he depends on the licensed nursing staff's judgment (when they call him) if a resident, such as Resident 70, wants to go out on pass. The physician mentioned that he does not feel comfortable for a resident, with psychological problems, to go out on pass (alone); unless the out on pass order is approved by the resident's responsible party, family or conservator, and accompanied by an adult. The physician stated, I don't want to be responsible for a resident to go out on pass, alone." On 11/21/14, at 1:45 p.m., an interview was conducted with Resident 70's psychiatrist regarding the resident's out on pass order. During this interview, the psychiatrist stated that the licensed nursing staff assess the residents to determine if they are suitable to go out on pass. If the residents have a responsible party, family or conservator, the nursing staff must communicate with the responsible parties to get their approval for the resident to go out on pass. On 11/25/14, at 1:30 p.m., an interview was conducted with the administrator regarding Resident 70's death. The administrator was asked to explain the facility?s policy regarding out on pass. The administrator stated the physician has to conduct an assessment and approve the out on pass. The administrator was then asked how Resident 70 who had diagnoses of schizophrenia, psychosis, and anxiety disorder, a history of 5150 (An involuntary psychiatric hold due to a mental disorder that makes a person danger to themselves, and/or a danger to others.), before her original admission, at acute psych #1 and acute psych #2, and had two explosive episodes of yelling and screaming, on 12/16/13, and on 2/3/14, which caused the resident to be transferred out for further evaluation was allowed to go out on a pass alone? The administrator did not provide an answer. The facility failed to ensure Resident 70 received adequate supervision to prevent accidents by failing to ensure the attending physician conducted an assessment as indicated in their policy and procedure prior to allowing the resident to leave out on pass unaccompanied by a responsible adult. This deficient practice consequently resulted in the actual harm and subsequent death of Resident 70, due to third degree burns.The above violation presented a substantial probability that death or serious physical harm would result. |
| 970000077 |
South Pasadena Care Center |
950011293 |
A |
05-Mar-15 |
3MWO11 |
12759 |
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.During a Recertification Visit on 5/13/14, a Code Blue was called. During the Code Blue the nursing staff did not use the proper technique for providing chest compressions and did not deliver the correct amount of chest compressions to a resident who was Full Code Status.The facility failed to ensure cardiopulmonary resuscitation (CPR/ lifesaving technique useful in many emergencies) was performed correctly by certified nursing assistant (CNA 1) and licensed vocational nurse (LVN 1) by failing to: 1. Ensure the nursing staff (CNA 1) used the proper technique for providing chest compressions to Resident 12, by not delivering chest compressions to the center of the resident's chest. 2. Ensure LVN 1 provided the correct amount of chest compressions, as indicated by the CPR Guidelines (American Heart Association) for Resident 12 during a Code Blue (code used to alert staff of a medical emergency in the facility) emergency response. 3. Ensure staff (CNA 1, CNA 2, physical therapist assistant, RN 1, CNA 3, CNA 4, CNA 5, CNA 7, CNA 8, RN 2) were knowledgeable of how to respond correctly, if they were to find an unresponsive resident. CNA 2, RN 1, CNA 3, CNA 4, CNA 5, CNA 7, CNA 8, RN 2, responded with the incorrect ratio of Chest Compressions to Ventilation in two person adult CPR and the proper hand position for delivering CPR chest compressions. This resulted in Resident 12 not receiving an effective resuscitation effort during a Code Blue in violation of the resident's right to be fully resuscitated, as indicated in the resident's wishes for life sustaining treatment of Full Code status (if cardiopulmonary arrest-stop breathing or the heart stops beating the medical staff will intervene and perform CPR.Resident 12 was a 67 year old female who was readmitted to the facility on 10/30/13, with diagnoses that included a history of dysphagia (difficulty swallowing), hypertension (high blood pressure), and chronic airway obstruction (upper or lower airway is chronically obstructed). The Physician Orders for Life-Sustaining Treatment (POLST/a standardized medical order form that indicates the specific types of life-sustaining treatment a resident wishes and does not wish in a medical emergency) dated 10/30/13, indicated Resident 12 wished for CPR, full treatment that includes intubation (placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway) and long-term artificial nutrition (nutrition in any form other than the taking in of food through the mouth). The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 2/20/14, indicated the resident usually was able to express ideas/needs and understand others. It further indicated the resident required limited to extensive assistance for activities of daily living. During an observation at 8:10 a.m., LVN 2 was seen proceeding to the nursing station where she announced "Code Blue" to Resident 12's room. Upon arrival to Resident 12's room, Resident 12 was lying in the bed with her eyes open while a breathing treatment was being administered via a face mask (a facial mask which is placed over the resident's nose and mouth to administer medication). CNA 1 and LVN 1 were observed attempting to deliver CPR from 8:10 a.m. until 8:18 a.m., when the Fire Department staff arrived to Resident 12's room and intervened. During CPR efforts, at 8:10 a.m., CNA 1, attempted to deliver chest compressions, while the resident was flat on the bed.According to the American Heart Association (AHA) Guidelines January 2014: CPR should be performed when the victim is lying flat on a hard surface. Immediately following the initial attempt to deliver chest compressions, the resident was lowered to the floor and CNA 1 resumed chest compression. CNA 1 placed her hands over the right side of Resident 12's chest and performed chest compressions instead of the center of her chest. According to the American Heart Association: The chest compressions are to be performed at the lower half of the breast bone (center of the chest over the sternum).At 8:15 a.m., LVN 1 intervened and delivered 36 compressions for the first cycle (AHA guidelines=30 compressions and 2 breaths) of CPR, then 29 compressions for the second cycle and 28 compressions for the third cycle. During the CPR cycles there was no verbalization of the compression count by CNA 1 and LVN 1.According to the EMT Run sheet, a call was received from the facility on 5/13/14, at 8:11 a.m. EMT were dispatched at 8:12 a.m. and arrived on the scene at 8:17 a.m. The case was closed at 8:44 a.m. At 8:18 a.m., the Fire Department responders arrived on scene and asked the facility staff how long they had been performing CPR. RN 1 responded 15 minutes. The surveyor noted the time CPR started until the Fire Department arrived was 8 minutes. At 8:28 a.m., the Fire Department staff notified the facility staff the resident was pronounced expired by the physician from the acute hospital. (This was done remotely. The resident was not transferred to the acute hospital. The EMT made contact with the acute hospital (Base Hospital) and the Physician made the pronouncement of death by radio communication and then ceased resuscitative efforts. There was no acute hospital transfer).The death certificate indicated the resident expired 5/13/14, at 8:28 a.m. at the facility. The immediate cause of death was cardiorespiratory arrest, cardiomyopathy and hypertension.According to American Heart Association the current CPR Guidelines January 2014, indicated: "-First call 911. If not, others to call. -Make the victim respond. If he/she does not respond, roll him/her on his/her back. -Start giving chest compressions by placing the heel part of the hand on the center of the chest of the victim, with the other hand placed on top of it, with interlaced fingers. -Now press down and compress the chest approximately 2 inches in case of children and adults... -Carry on giving chest compressions and breaths in the ratio - 30:2 for 100 compressions per minute, till the time any medical assistance arrives."( http://www.cprcertificationonlinehq.com/aha-cpr-guidelines-latest-jan-2014) During interviews on 5/13/14, 13 certified and licensed staffs were asked about the proper procedure to follow if they found an unresponsive resident and/or their knowledge of the current CPR guidelines. Ten of 13 staff members responded with incorrect information per the facility's policy and current CPR Guidelines. During an interview on 5/13/14, at 8:25 a.m., CNA 1 was asked to describe how to administer CPR. CNA 1 stated when administering CPR an individual should administer 30 compressions and 2 breaths to the individual. CNA 1 stated, "I placed one hand on top of the other under the breast bone and I gave compressions." CNA 1 further stated, "I wasn't counting". On 5/13/14, at 8:42 a.m., CNA 2 responded she did not know the number of compressions.On 5/13/14, at 8:50 a.m., the physical therapist assistant responded he would check the throat and call for help and made no mention if CPR would be initiated.On 5/13/14, at 8:51 a.m., a registered nurse (RN 2) stated she would perform compressions for 90 seconds/ 90 compressions.On 5/13/14, at 8:53 a.m., CNA 3 responded by saying she would perform 15 compressions and will continue with compressions until someone relieves her.On 5/13/14, at 9:04 a.m., CNA 4 stated she would perform compression under the stomach.On 5/13/14, at 9:05 a.m., CNA 5 did not provide a response when questioned regarding the location of delivering chest compression during CPR.On 5/13/14, at 9:14 a.m., CNA 7 stated when giving CPR, one should give 10 compressions, wait to see if the resident is breathing and if he or she is not breathing, then one should give 2 breaths. According to the CNA 7, the procedure of 10 compressions to 2 breaths should continue until the fire department arrives. On 5/13/14, at 9:25 a.m., CNA 8 stated the proper placement of the hands during CPR is to place the hand over the left breast, clasp the hands together and begin compressions. On 5/13/14, at 9:55 a.m., RN 1 responded she would perform continuous compressions and check for pulse every 2 minutes.On 5/13/14, during an interview with RN 1, at 11:08 a.m., she was asked how many codes blue the facility has had within the last three months. She stated there were a total of three codes blue performed on 4/19, 4/23, and 5/13/14, and each resident expired in the facility. A review of the facility resident's wishes for the specific types of life-sustaining treatment, indicated 141 of the total census of 149, wished to have life-sustaining treatment of CPR.During an interview with the director of staff development on 5/13/14, at 11:10 a.m., she stated staff have not had an in service on CPR, however, on April 21, 2014, she held a CPR class for staff who had expired CPR certification cards. A review of Resident 12's clinical record with the DON, on 5/15/14, at 9:37 a.m., indicated the nurses' progress notes, dated 5/13/14, at 8:15 a.m., noted that the charge nurse was notified by the social worker that Resident 12 was complaining of difficulty breathing and a code blue was announced. A review of the dispatch record, from the 911 call to the Fire Department, dated 5/13/14, indicated the call was received from the facility at 8:11 a.m. and the emergency response team was dispatched to the facility at 8:12 a.m.During an interview with LVN 4 on 5/14/14, at 2:17 p.m., she stated she was asked by the social service designee (SSD 1) to administer a breathing treatment (medication to treat breathing impairment) to Resident 12. When she was administering the breathing treatment the resident's skin color became "pale" and she called for help. During the interview with LVN 4, she was asked if she examined the resident prior to obtaining the breathing treatment, she responded, "No". She further added she went directly to obtain the breathing treatment from the resident's medication nurse. During an interview with LVN 2 on 5/14/14, at 2:25 p.m., she stated she was in room 211 administering medication when LVN 4 approached her and asked for the medication cart keys to get the breathing treatment for Resident 12. Immediately after LVN 4 left, LVN 2 went to Resident 12's room and observed LVN 4 administering breathing treatment and yelling for help. The facility failed to ensure cardiopulmonary resuscitation (CPR/ lifesaving technique useful in many emergencies) was performed correctly by certified nursing assistant (CNA 1) and licensed vocational nurse (LVN 1)by failing to: 1. Ensure the nursing staff (CNA 1) used the proper technique for providing chest compressions to Resident 12, by not delivering chest compressions to the center of the resident's chest.2. Ensure LVN 1 provided the correct amount of chest compressions, as indicated by the CPR Guidelines (American Heart Association) for Resident 12 during a Code Blue (code used to alert staff of a medical emergency in the facility) emergency response. 3. Ensure staff (CNA 1, CNA 2, physical therapist assistant, RN 1, CNA 3, CNA 4, CNA 5, CNA 7, CNA 8, RN 2) were knowledgeable of how to respond correctly, if they were to find an unresponsive resident. CNA 2, RN 1, CNA 3, CNA 4, CNA 5, CNA 7, CNA 8, RN 2, responded with the incorrect ratio of Chest Compressions to Ventilation in two person adult CPR and the proper hand position for delivering CPR chest compressions. As a result of the facility?s failure, Resident 12 did not receive an effective resuscitation effort during a Code Blue in violation of the resident's right to be fully resuscitated, as indicated in the resident's wishes for life sustaining treatment of Full Code status (if cardiopulmonary arrest-stop breathing or the heart stops beating the medical staff will intervene and perform CPR), and put the other residents at risk for provision of ineffective resuscitation effort during a Code Blue. These deficient practices had the potential to result in physical injury to residents, such as: fractured ribs, punctured lungs, and lacerated liver (a tear or cut in the liver), caused by improper and incorrect chest compressions for the 141 of 149 residents in the facility who have requested full Code status. These violations presented a substantial probability that death or serious physical harm would result. |
| 970000077 |
South Pasadena Care Center |
950011326 |
A |
10-Apr-15 |
DM3W11 |
7440 |
?72311.Nursing Service-General. (a) Nursing service shall include, but 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. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. Based on observation, interview, and record review, the facility failed by not: 1. Implementing Patient 2?s plan of care, who had an indwelling urinary catheter (drains urine from the bladder into a bag outside the body) and was at risk for urinary tract infections (UTIs) in monitoring her urine characteristics.2. Reporting to Patient 2?s physician when the urine characteristic changed as stipulated in the care plan. These failures resulted in Patient 2?s physician not being informed of the patient?s change in urine characteristics, which was later identified as a UTI, and resulted in a delay in diagnosing and treatment of the UTI. On February 9, 2015, at 7:15 a.m., during a licensing survey initial tour, accompanied by a licensed nurse. Patient 2 was observed lying flat in bed with an indwelling catheter bag hanging on the left side of the bed next to the privacy/dignity bag and not inside the bag. The urine was observed scant in amount, thick, dark orange-amber (midway between the color gold and orange) in color with sediment (consists of cells, debris and other solid material from urine) . The room had a strong smell of urine. A review of Patient 2?s Admission face Sheet indicated the patient was a 73 year-old female, who was admitted the facility on October 6, 2011 and re-admitted on September 30, 2014. The patient?s diagnoses included a Stage IV pressure ulcer (Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule) on the buttocks, requiring an indwelling urinary catheter for wound management, atrial fibrillation (most common abnormal heart rhythm), and hyperlipidemia (involves abnormally elevated levels of any or all lipids and/or lipoproteins in the blood [fats]). A Minimum Data Set (MDS), an assessment and care screening tool, with a reference date of January 31, 2015, indicated Patient 2 had the ability to understand and be understood, but was unable to identify the day, year, or month. According to the MDS, Patient 2 was non-ambulatory and required extensive assistance to being totally dependent upon staff for care. The patient was always incontinent (inability to control) of bowel and had an indwelling urinary catheter in place for urination. At 2:30 p.m., on February 9, 2015, the treatment nurse (LVN 1) was called to Patient 2?s bedside to assess her urine. When he was asked to assess the urine, he initially stated the patient?s urine characteristic looked normal, but then stated it was a little cloudy. LVN1 stated his responsibility, as the treatment nurse, included checking the patient?s urine, documenting the results and reporting the findings to the physician. However, there was no documentation in the patient?s record about the patient?s urine being concentrated and dark in color. A review of a SBAR (a nursing communication/situation, background, assessment and request) Assessment form, dated February 9, 2015, and timed at 2 p.m., indicated the patient?s urine was noted to be dark yellow-orange in color with cloudiness. The SBAR indicated the patient?s physician was called at 2 p.m., and vital signs were taken and recorded. The physician gave an order to obtain a urinalysis (UA/used to test for drugs, pregnancy, or diseases and conditions) and a culture and sensitivity ([C/S] microscopic study of urine to determine the presence of pathogenic bacteria in patients with suspected urinary tract infection to isolate potential pathogenic bacterium followed by antibiotic susceptibility testing). On February 9, 2015 at 2:50 p.m., the assistant director of nursing (ADON) was asked if Patient 2 was included in the facility?s UTI surveillance tracking. The ADON stated they have not tracked the patient, because she has never had an UTI.A review of the UA results, collected on February 10, 2015, indicated Patient 2?s urine was identified as amber in color and turbid (cloudy, opaque, or thick with suspended matter) in appearance had 50 white blood cells (WBCs) with a normal reference range of 0-5 HPF and many bacteria. The C/S results, dated February 12, 2015, indicated there were three organism identified; with Escherichia coli being the most with 100, 000 colonies/ML. On February 11, 2015, at 7:08 a.m., Patient 2 was observed to have approximately 100 milliliter (ml) of dark amber urine in urinary catheter bag. During an interview, on February 12, 2015, at 8:50 a.m., the ADON stated Patient 2 has a UTI and the nurses should have been monitoring the urine and report the results to the patient?s physician. At 9:30 a.m., on February 12, 2015, during a telephone interview, the facility?s medical director stated, ?As much as possible we should try not use Foley catheters (F/C), depending upon the indication of its use and when we do we should monitor for UTIs, not just the lab, but clinically.? The medical director stated they always discussed the issue of F/C usage, because if the patient does not need it, it should be removed, because it put the patient at risk for UTIs. A review of a physician?s telephone order, dated February 12, 2015, and timed at 4:20 p.m., indicated Ciprofloxacin (an antibiotic) 500 mg by mouth twice a day for seven days was ordered for Patient 2?s UTI. A review of several nurses? progress notes, after the urine characteristic was brought to LVN 1?s attention, from February 9, 2015 on the 3-11 p.m. shift until February 13, 2015, was being assessed by the licensed nurses as being dark yellow-orange in color with cloudiness. A review of a care plan, titled, ?Alteration in urinary elimination secondary to the use of a Foley catheter,? indicated the goal was the patient would have reduced of infection daily for 90 days. The staff?s approaches included monitoring urine for sediment, cloudiness, odor, blood, and the amount of output, and report any of the changes to the physician promptly. A review of the facility?s policy, titled, ?Change in Condition? with a revised date of January 1, 2012, indicated the purpose of the policy was for the staff to ensure family and physicians were informed of changes in the patient?s condition in a timely manner. It also stipulated the licensed nurse would notify the physician regarding a significant change in the patient?s physical, mental or psychosocial status. The facility failed by not: 1. Implementing Patient 2?s plan of care, who had an indwelling urinary catheter and was at risk for urinary tract infections (UTIs), in monitoring her urine characteristics.2. Reporting to Patient 2?s physician when the urine characteristic changed as stipulated in the care plan. The above violations either jointly, separately, or in any combination presented an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 970000077 |
South Pasadena Care Center |
950011327 |
A |
10-Apr-15 |
DM3W11 |
9332 |
?72313. 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. An announced complaint investigation was conducted on February 9, 2015. Based on interviews and record reviews, the facility failed by not: 1. Ordering the prescribed morphine sulfate (MS) timely for Patient 1?s administration. 2. Administering the prescribed MS twice a day for two days. These failures resulted in Patient 1 experiencing severe abdominal pain, nausea and vomiting, with the inability to eat, resulting in dehydration (occurs when the amount of water leaving the body is greater than the amount being taken in). Patient 1 required a transport to a general acute care hospital (GACH) for further evaluation and was admitted for six days. A review of the facility?s transfer form, dated January 13, 2015, indicated Patient 1 transferred to the GACH due to nausea and vomiting. A review of the history of the patient?s ?present illness? documentation from the GACH, indicated the patient complained of abdominal pain, nausea with vomiting two-three times a day two days prior to his arrival to the emergency room (ER) on January 13, 2015. According to the GACH?s documentation, the patient stated he thought his symptoms were due to morphine withdrawal, since he had been on morphine for ten years and had not received it for two days. The GACH?s triage assessment indicated the patient?s pain level was 10/10 (10 being the worse). Patient 1 was given 4 milligram (mg) of morphine intravenous push ([IV push] into the vein) upon his arrival and later in the evening while in the emergency room (ER). Once admitted, the patient received morphine 60 mg twice a day by mouth. Patient 1 was also diagnosed as being dehydrated with an elevated BUN (blood urea nitrogen) and a creatinine (a blood test which measures the level of creatinine in the blood, to see how well the kidneys are working). The BUN test is primarily used, along with the creatinine test, to evaluate the kidney?s function. Patient 1?s creatinine was elevated on January 13, 2015, at 1.9 milligram per deciliter (mg/dL) (normal reference .6-1.3) and the BUN was elevated to 25 mg/dl (normal reference 7-18). Patient 1 was hydrated with a 1000 milliliter of sodium chloride 0.9% IVF via IV. The patient continued to vomit upon his arrival to the ER, which was preventing the patient from undergoing the diagnostic exams ordered by the physicians and was given Zofran (used to prevent nausea and vomiting) 4 mg via IV to control the vomiting. A review of an article by Medline Plus, US National Library of Medicine, titled ?Opiate Withdrawal? indicated it refers to the wide range of symptoms that occur after stopping or dramatically reducing opiate drugs (heroin, morphine, codeine etc.) after heavy or prolonged use. According to the article, symptoms included abdominal cramping, diarrhea and nausea. The complications included vomiting and diarrhea, because it can cause dehydration and result in the body?s chemical and mineral electrolyte imbalance. The article indicated the biggest complication of opiate withdrawal is that most overdoses occur after a person had gone through withdrawals, because their tolerances for the medication are reduced. A review of the patient?s GACH?s history and physical (H/P), dated January 14, 2015, indicated the patient was receiving MS, but ran out of medications due to a miscommunication. The patient started having abdominal pain with nausea, vomiting, and cramping with the inability to eat. According to the H/P, the patient was receiving the MS for chronic pain syndrome associated with paraplegic (an impairment in motor or sensory function of the lower extremities with the inability to walk/ status-post a gunshot wound), Stage IV pressure ulcer (deep sore, reaching into muscle and bone and causing extensive damage), osteomyelitis (bone infection) and neurogenic bladder (lacks bladder control due to a brain, spinal cord, or nerve condition) with a supra pubic (pertaining to a location above the symphysis pubis [above the pubic bone]) catheter (a thin, sterile tube used to drain urine directly from the bladder).On February 11, 2015, at 7:15 a.m., Patient 1 was observed in his bed. He was questioned about not receiving his MS timely last month. He stated, ?There have been many more times that I did not receive the MS.? A review of Patient 1?s facility?s admission Face Sheet indicated the patient was a 53 year-old male admitted to the facility on November 6, 2011. The patient?s diagnoses included Stage IV buttocks pressure ulcer, psychiatric disorders, intestinal obstruction, paraplegia, and chronic pain syndrome (ongoing pain lasting longer than 6 months). A review of the physician?s recapped order, dated November 23, 2013, indicated morphine sulfate 60 mg to be given orally (by mouth) every 12 hours (9 a.m. and 9 p.m.) for severe pain. A review of a Minimum Data Set (MDS), an assessment and care screening tool, with an assessment date of November 21, 2014, indicated the patient had the ability to understand and be understood and had the ability for recall. According to the MDS, Patient 1 was non ambulatory (paraplegic), but required only minimal assistance with bed mobility, dressing, and transferring. The patient used an electric wheelchair for locomotion. The MDS, under JO400; Pain Frequency, indicated the patient frequently had pain and received pain medication routinely and PRN (whenever necessary). A review of the Medication Administration Record (MAR) for January 2015, indicated on January 12, 2015, the nurse circled the MS 60 mg, both the morning dose (9 a.m.) and the evening dose (9 p.m.) to indicate it was not given. On January 13, 2015, Patient 1 did not receive his MS. During the investigation, several attempts were made to interview Patient 1, but he became hostile and refused to be interviewed and attempted to run the evaluator over with his wheelchair. A review of Patient 1?s narcotic controlled drug record for Morphine Sulfate 60 mg indicated 60 tablets were dispensed on December 9, 2014 for the 9 a.m. and 9 p.m. dosages. The patient received the first dose of the 60 tablets on December 13, 2014, for both morning and evening, and the last dosage was issued to the patient on January 11, 2015, at 9 p.m. There was no more MS available for administration to Patient 1. Also, a review of the emergency narcotic kit (E-kit) tracking from the dispensing pharmacy indicated there were no narcotics removed from the facility?s E-kit during the time frame of January 11-13, 2015. At 10:15 a.m., on February 11, 2015, the medication nurse (LVN 4) stated, ?We sometimes fax the physician?s orders to the pharmacy.? She stated there has been a delay in the narcotics being dispensed from the pharmacy. On February 11, 2015, at 4:44 p.m., during a telephone interview, a pharmacist (Pharmacist 2) from the facility?s dispensing pharmacy stated they have had many problems dispensing narcotic timely to the facility. She stated there has been an ongoing problem and delay in the patients receiving their narcotics timely. Pharmacist 2 stated the problem was that the nurses sent the requests over too late for the pharmacist to get the physicians to approve. She stated they have made several attempts to work with the facility to ensure the patients received their medications timely. At 8:15 a.m., on February 12, 2015, the assistant director of nurse (ADON) stated the facility has problems with patients receiving their narcotics as prescribed by the physician because the medications are not delivered timely. On February 12, 2015, during a telephone interview, at 9:30 a.m., the facility?s medical director stated he was aware of the facility?s delay in receiving narcotics because they have been discussing it in the Quality Assurance (QA) meetings. He stated they were trying to correct it and make changes, but stated he will speak to the other physicians to ensure they will start calling back timely for approval of the narcotic prescriptions. He stated, ?The patients are the ones who suffer when the narcotics and pain medications are not available.? On February 12, 2015 at 10:45 a.m., the supervising pharmacist (Pharmacist 1), from the facility?s dispensing pharmacy, called and stated there has been an ongoing problem with dispensing narcotics to the facility because the facility sends the request without a prescription from the physicians. He stated they (the pharmacists) in turn have to make several calls to the physicians, who do not always call back. Pharmacist 1 stated they have created a line of communication with the facility and have informed them if they would submit E-prescriptions or a written prescription they could dispense the narcotics timely for the patients. The facility failed by not: 1. Ordering the prescribed morphine sulfate (MS) timely for Patient 1?s administration. 2. Administering the prescribed MS twice a day for two days. The above violations jointly, separately or in any combination presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 970000077 |
South Pasadena Care Center |
950011328 |
A |
10-Apr-15 |
DM3W11 |
7646 |
?72315.Nursing Service Patient Care. (f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include: (1) Changing position of bedfast and chair fast patients with preventative skin care in accordance with the needs of the patient. Based on observation, interview, and record review, the facility failed by not: 1. Implementing Patient 2?s plan of care, for her existing decubitus (pressure ulcer), which stipulated the patient would be turned every two hours. 2. Providing pain medications to Patient 2 prior to providing wound care to such a large deep wound. These failures had the potential for the existing decubitus to get worse and put the patient at risk for developing further decubitus. The failure of the facility to provide pain medication prior to wound treatment, as prescribed by the physician, put Patient 2 in undue pain and discomfort. On February 9, 2015, at 7:15 a.m., during a licensing survey initial tour, accompanied by a licensed nurse (LVN 5), Patient 2 was observed lying flat in bed on a low air loss (LAL) mattress, used for the treatment and prevention of pressure ulcers. LVN 5 stated the patient had a pressure sore, but he was unaware of the stage (I, II, III, or IV).Patient 2 was observed lying flat on her back without heels floating (off mattress, to prevent pressure) on several occasions on February 9, 2015, at 10 a.m., 12:05 p.m. and 1:30 p.m., and on February 11, 2015, at 10:30, 11:40 a.m., 2:10 p.m., and at 4 p.m. without being repositioned. On February 12, 2015 at 7 a.m., 7:45 a.m. and 10 a.m., the patient remained on her back without being repositioned every two hours. A review of Patient 2?s Admission Face Sheet indicated the patient was a 73 year-old female, who was admitted to the facility on October 6, 2011 and re-admitted on September 30, 2014. The patient?s diagnoses included a Stage IV pressure ulcer (Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures [e.g., tendon, joint capsule]) on the buttocks, requiring an indwelling urinary catheter for wound management, atrial fibrillation (most common abnormal heart rhythm), and hyperlipidemia (involves abnormally elevated levels of any or all lipids and/or lipoproteins in the blood [fats]). A Minimum Data Set (MDS), an assessment and care screening tool, with a reference date of January 31, 2015, indicated Patient 2 had the ability to understand and be understood, but was unable to identify the day, year, or month. According to the MDS, Patient 2 was non-ambulatory and required extensive assistance to being totally dependent upon staff for care, which included turning and repositioning. The patient was always incontinent (inability to control) of bowel and had an indwelling urinary catheter in place for urination for wound management. A review of the ?Braden Scale ?for predicting pressure sore risk,? initiated on September 30, 2014, and last reviewed on October 21, 2014, indicated Patient 2 had a score of 10. According to the scale, a total score of 12 or less represents HIGH RISK. A care plan, dated September 30, 2014 and last updated December 2014, titled ?Risk for developing pressure sore, bruising, and other types of skin breakdown related to the patient?s history of skin alterations, reduced mobility and incontinence of bowel and bladder. The patient?s goal was to minimize the risk of skin breakdown/pressure sores by 90 days. The staff?s plan of approaches included turning and repositioning in bed and chair, using pressure relieving devices, providing treatments as ordered and monitoring for signs of pain and discomfort and medicate as ordered. According to the Medication Administration Record (MAR), for the month of February 2015, the patient had an order for Norco 5- 325 mg (used for the relief of moderate to moderately severe pain/ 5 mg of hydrocodone bitartrate and 325 mg of acetaminophen tablet) to be given a half-hour prior to wound care treatment every day, that was ordered on January 16, 2015. According to the MAR, the patient refused the medication on February 5-11, 2015, without any documentation the patient?s physician was made aware. On February 11, 2015 at 8:40 a.m., during the patient?s wound care observation, with LVN 1, LVN 1 was observed removing the wound dressing before asking the patient if she had any pain. The large deep sacral wound, measured 7 by 5.5 centimeters (cm) in size and 1.5 cm in depth. The sacral wound had bloody drainage with some slough (necrotic tissue in the process of separating from viable portions of the body; to shed or cast off) and some muscle and bone was visible. LVN 1 asked the patient several times if she was in pain while he heard her moan. LVN 1 was asked why she was not pre-medicated and he stated, ?The patient usually refused medications by mouth and I do not have an order for an intramuscular (IM) pain medication.? On February 12, 2015, at 10 a.m., Patient 2?s certified nurse assistant (CNA 4) stated she was assigned to the patient that day and the patient had to be turned every two hours. She stated when she was on duty she would turn the patient every two hours. She stated she was on duty on Monday, February 9, 2015, and was assigned to Patient 2. When she was informed that the patient was observed on that day on her back, not turned every two hours, as stipulated in the patient?s plan of care, CNA 4 did not respond. At 10:05 a.m., on February 12, 2015, the treatment nurse was asked in the presence of the director of nurses (DON), why he did not pre- medicate the patient. He stated, ?The patient always refuses the Norco.? The DON stated the physician should had been called and maybe an IM injection given. The DON asked the treatment nurse if he had asked the patient if she was in pain and LVN 1 stated, ?Yes.? However, the evaluator informed the DON the patient did not respond, but continued to moan. The DON stated the patient did not have the capacity to make decisions. On February 12, 2015, at 10:30 a.m., CNA 4 came and stated she will turn Patient 2 now, and at 12:30 p.m. According to an online article, by the US National Library of Medicine National Institutes of Health (NIHPA), titled ?Wound Repair Regen,? dated January 19, 2011, indicated pressure ulcers are a common complication of immobility among the elderly, resulting in substantial pain and suffering and excess hospital costs. The article indicated methods for prevention of pressure ulcers is the frequent manual repositioning of patients with limited mobility. In particular, several clinical guidelines recommend that bedbound patients be repositioned every two hours. A review of the facility?s policy, titled, ?Skin and Wound Management? with a revise date of January 1, 2012, indicated the purpose of the policy was to maintain and/or improve patient?s tissue tolerance in order to prevent injury and/or infection, skin breakdown, the potential for skin breakdown, and the risk for the development of pressure ulcers and/or other skin conditions. The facility failed by not: 1. Implementing Patient 2?s plan of care, which stipulated the patient would be turned every two hours. 2. Providing pain medications prior to providing wound care to such a large deep wound. The above violations either jointly, separately, or in any combination presented an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 970000077 |
South Pasadena Care Center |
950011329 |
B |
10-Apr-15 |
DM3W11 |
9222 |
?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 a complaint alleging a patient (Patient 19) went missing from the facility and was last seen by the staff getting in a cab on May 24, 2014. The police made several calls to a family member and listed names on the patient?s Admission Face Sheet in an attempt to locate the patient unsuccessfully. An announced complaint investigation was conducted on February 9, 2015. Based on interview and record reviews, the facility failed by not: 1. Following its policy and procedure regarding elopement. 2. Reporting to the Department of Patient 19?s elopement. 3. Investigating further of the whereabouts of Patient 19. 4. Reporting the missing patient timely to the police. These failures put Patient 19 at risk for health concerns being without her medications; harm due to her mental status and at risk for falls and injury due to her unsteady gait. According to the general acute care hospital (GACH) records the patient presented to the emergency room (ER) in an unstable condition rambling, agitated, hyper-verbal and suspicious, requiring an admission to the intensive psychiatric ward. A review of the police report indicated on Sunday, May 25, 2014, at 7:13 p.m., which was a day after the patient went missing; the police were dispatched to the facility in response to Patient 19 being missing. The police were unable to locate the patient and to speak to the next of kin of the missing patient. A review of Patient 19?s Admission Face Sheet indicated the patient was a 49 year-old female, who was admitted to the facility on October 4, 2012. The patient?s diagnoses included hypothyroidism (a condition in which the body lacks sufficient thyroid hormone), asthma (chronic inflammatory disease of the airways), malignant hypertension (a condition in which elevated blood pressure results in target organ damage), and depressive and mental disorders. All Patient 19?s diagnoses required medications for maintenance control.A review of a Minimum Data Set (MDS), an assessment and care screening tool, with a referenced assessment date of March 6, 2014, indicated Patient 19 had the ability to understand and be understood, was ambulatory and required minimal assistance with her activities of daily living. The MDS, under Section C for cognition patterns, indicated the patient had disorganized thinking with incoherent (incomprehensible; unclear: unintelligible) conversation. The MDS indicated the patient exhibited feeling down, depressed and hopelessness. The MDS, under Section G0300, indicated the patient was not steady in walking, moving from sitting to standing, turning around or moving from surface to surface. A review of the physician?s recapped orders for May 2014, indicated the patient was receiving Synthroid 100 mcg (micrograms) every day for hypothyroidism, Norvasc 5 milligram (mg) every day for hypertension, albuterol 2.5 mg INH PRN (whenever necessary) for shortness of breath and wheezing maintenance for asthma, Klonopin 0.5 mg twice a day for anxiety and agitation, Remeron 30 mg every night for depression and Abilify 30 mg every day for Patient 19?s mental disorder manifested by mood swings. A review of a physician?s telephone order written by a nurse, dated May 24, 2014, indicated ?D/C AMA (against medical advice),? signed by the physician. A review of an Elopement Risk Assessment, initiated on December 2, 2013 and an updated assessment on March 11, 2014, indicated the patient had a score of 15 and for the score of 14-20 represented moderate risk and required care planning. However, there was no plan of care to address Patient 19?s risk for elopement, even after she expressed the desire to leave weeks and days prior to eloping. A social service note, dated April 11, 2014, without a time, indicated Patient 19 was agitated and stating she wanted to leave the facility with $500.00 cash she had in her possession. The note indicated the social worker informed the patient she could not keep that large amount of money at the bedside because it was against the facility?s policy, but the patient stated, ?I can and I will keep it safe.? Another social worker note, dated April 14, 2014, without a time, indicated the patient was very upset and continued to say she was leaving the facility. On April 15, 2014, the social worker?s note indicated she offered to place the patient in a lower level of care (B/C-board and care), but the patient declined. A review of a nurse?s note, dated May 24, 2014 and timed at 7 a.m., indicated the patient was seen sitting on the couch verbalizing she wanted to go home. Two hours later, the nurse wrote the patient stated, ?I really want to go out of this facility.?On February 11, 2015, at 12 p.m., the administrator was asked for the investigation report regarding Patient 19?s elopement and he initially stated there was no investigation conducted because the patient went AMA. He also stated he did not report the elopement to the Department, but did notify the police on May 24, 2014, which conflicts with the time frame the police indicated they were dispatched (police dispatched on May 25, 2014). The administrator returned an hour later presenting a one-page typed investigation report, dated May 24, 2014, indicating the patient left the facility at approximately 11:30 a.m., on May 24, 2014. Under Immediate Action, the report indicated due the concern of the patient?s safety, the police were notified on May 24, 2014, at 7:30 p.m., over seven hours after the patient eloped, contrary to the police report. Attached to the report was a hand written statement by a staff member indicating Patient 19 walked out of the facility?s front door and got into a cab on May 24, 2014 at 12 p.m. The facility?s report indicated hospitals were called for the patient?s whereabouts and the patient was located self-admitted to a general acute care hospital (GACH) on the same day on May 24, 2014. However, the police report indicated they were dispatched on May 25, 2014. During a concurrent interview and record review, on February 11, 2015, at 2:55 p.m., the director of nurses (DON) stated after reviewing Patient 19?s record, there should have been a care plan to address the patient being at risk for elopement. She also stated, ?I was not the DON when the patient eloped, but if I were, I would have continued to call and document that we were looking for the patient to ensure her safety.? The DON stated the staff should have follow-up on the patient?s whereabouts as soon as she eloped. The DON stated there is a difference between a patient leaving AMA (against medical advice) and eloping from the facility. She stated she did not know why the staff would write a telephone order for AMA when the patient eloped. The DON stated the patient?s record should have indicated if the patient was found and where she was. The patient?s record had no documented evidence the facility called the patient?s next of kin, the police, the ombudsman, and or the Department of Patient 19?s elopement. A review of the GACH?s ER records, dated May 24, 2014, indicated the patient arrived at the ER at 11:26 a.m., which conflicts with the timeframe the facility indicated the patient went missing. The physician documented the patient presented with agitation and psychiatric problems with a history of hypertension, thyroid disease, hallucinations (a perception in the absence of external stimulus that has qualities of real perception), and attempted suicide. The discharge summary indicated the GACH found out the patient was missing from a nursing home, in which the patient refused to go back to. The GACH put the patient on a conservatorship (legal concept, where a guardian and protector is appointed by a judge to manage the financial affairs and/or daily life of another due to physical or mental limitations, or old age) track due to her inability to take care of herself and being gravely disabled.A review of the facility?s policy titled, ?Wandering & Elopement? indicated the staff should try and prevent the patient from leaving first, but if the patient leaves the staff should search inside and outside for the patient. It also stipulated the administrator, DON, attending physician, responsible party, local law enforcement would be notified, in addition to the facility making necessary reports to the State agencies to report the unusual occurrence. The policy also indicated the administrator or designee will continue to work with law enforcement until the patient was located. The facility failed to follow the above policy to ensure the safety for Patient 19. The facility failed by not: 1. Following its policy and procedure regarding elopement. 2. Reporting to the Department of Patient 19?s elopement. 3. Investigating further of the whereabouts of the missing patient. 4. Reporting the missing patient timely to the police. The above violations had a direct or immediate relationship to the health, safety or security of Patient 19. |
| 970000077 |
South Pasadena Care Center |
950011330 |
A |
10-Apr-15 |
DM3W11 |
12862 |
?72527. Patients? Rights. (c) If a patient lacks the ability to understand these rights and the nature and consequences of proposed treatment, the patient?s representative shall have the rights specified in this section to the extent the right may devolve to another, unless the representative?s authority is otherwise limited. The patient?s incapacity shall be determined by a court in accordance with state law or by the patient?s physician unless the physician?s determination is disputed by the patient or patient?s representative. (2) How the facility, in consultation with the patient?s physician will identify consistent with current statutory case law, who may serve as a patient?s representative when an incapacitated patient has no conservator or attorney in fact under a valid Durable Power of Attorney for Health Care. Based on observation, interview, and record review, the facility failed Patient 2, who had mental disorders and did not have the capacity to make sound decisions by: 1. Not notifying Patient 2?s family, physician, and the facility?s medical director of her deteriorating condition due to her refusal to take her life sustaining medications, eat and drink at times. 2. Allowing Patient 2, who continued to eat and drink poorly, with a substantial weight loss, to refuse medications and treatments without staffs? interventions, after the physician documented the patient did not have the capacity to make decisions. These failures resulted in the patient losing 30 pounds in three months, developing a urinary tract infection, mental behaviors not being controlled; with the potential for dehydration (losing more water than taking in), potential for exacerbation of the current heart and thyroid problems; with the potential for the large Stage IV pressure ulcer (Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures [e.g., tendon, joint capsule]) to become worse and develop more pressure ulcers due to poor nutritional intake and the patient?s refusal to take vitamin supplements for wound healing.A review of Patient 2?s Admission Face Sheet indicated the patient was a 73 year-old female, who was admitted to the facility on October 6, 2011 and re-admitted on September 30, 2014. The patient?s diagnoses included a Stage IV pressure ulcer on the buttocks, requiring an indwelling urinary catheter (a tube placed in the body to drain and collect urine from the bladder) for wound management, hypothyroidism (a condition in which the body lacks sufficient thyroid hormone and requires supplement), atrial fibrillation (most common abnormal heart rhythm), and hyperlipidemia (involves abnormally elevated levels of any or all lipids and/or lipoproteins in the blood [fats]) and psychiatric disorders.A Minimum Data Set (MDS), an assessment and care screening tool, with a reference date of January 31, 2015, indicated Patient 2 had the ability to understand and be understood, but was unable to identify the day, year, or month. According to the MDS, Patient 2 was non-ambulatory and required extensive assistance to being totally dependent upon staff for care, which included turning and repositioning. The patient was always incontinent (inability to control) of bowel and had an indwelling urinary catheter in place for urination for wound management. Under Section E/Behavior, indicated Patient 2 exhibited both, hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS also indicated the patient had behaviors toward self and others, such as: threatening, screaming and cursing toward others and self-hitting and scratching. A review of a history and physical (H/P) of the patient?s admission at the general acute care hospital (GACH), dated September 22, 2014, indicated the patient was paranoid (having delusions of persecution [hostility and ill-treatment]) extremely agitated, yelling and screaming and becoming violent toward the staff. Patient 2 was admitted to the GACH for a psychiatric evaluation and treatment. A review of the ?Braden Scale ?for predicting pressure sore risk,? initiated on September 30, 2014, and last reviewed on October 21, 2014, indicated Patient 2 had a total score of 10, scoring a low score of 2, for inadequate nutrition. According to the scale, a total score of 12 or less represents HIGH RISK. The large deep sacral wound, measured 7 by 5.5 centimeters (cm) in size and 1.5 cm in depth. The sacral wound had bloody drainage with some slough (necrotic tissue in the process of separating from viable portions of the body; to shed or cast off) and some muscle and bone was visible. A review of a H/P, dated October 2014, after the patient returned to the facility from the GACH, the physician documented the patient went to the GACH due to exhibiting psychosis (symptom or feature of mental illness typically characterized by radical changes in personality, impaired functioning, and a distorted or nonexistent sense of objective reality), aggressive behavior, refusing to eat and have blood drawn for laboratory testing. The physician documented Patient 2 did not have the capacity to understand and make decision. A review of a ?Follow-up Weight Review,? dated November 6, 2014, indicated Patient 2 had poor meal intolerances due to distraction and throwing food. The planned interventions included; providing between meal snacks and an appetite stimulant (Megace), in which the patient refused to take.A review of a ?Monthly Record of V/S [vital signs] & WTS [weights]? indicated Patient 2 weighed 152 pounds (lbs.) in September and October 2014, in November 2014, the patient weighed 135 Ibs., a 17 pound weight loss; December 2014 the patient weighed 132, another 5 lbs weight loss; January 2015, Patient 2 weighed 127 pounds with another 5 pounds lost; and February 2015, the patient lost another 5 pounds, weighing only 122 pounds. A review of a social service note, dated November 26, 2014, without a time, indicated the patient was confused with periods of telling staff unrealistic stories. The note further indicated according to the physician?s evaluation, the patient did not have the capacity to make decisions. However, the staff continued to allow the patient to make decisions about her health. The note indicated the patient continued to refuse medications, so the physician discontinued the antipsychotic medications (Depakote and Seroquel). A care plan, dated January 27, 2015, titled, ?Non-complaint with nursing care and nursing interventions such as; refusing medications; picky with food intake; verbally abusive toward staff; refusing to turn and change diaper. The staff?s plan of approaches included offering alternatives, informing the patient of the ramifications of the continued non-compliance and to monitor for significant changes in condition and notify the physician. There was no documentation the staff involved a bioethics committee with plans for conservatorship for Patient 2, who did not have the capacity to make decisions and mental and physical health continued to deteriorate.According to the Medication Administration Records (MAR), for the months from September 2014 until February 2015, there were many days documented that Patient 2 refused her medications prescribed by the physician for her medical and psychiatric conditions (hypothyroidism, poor appetite [appetite stimulants], high cholesterol, atrial fibrillation, pressure ulcer, constipation, gastric-esophageal reflux disease [GERD] and most recently, an antibiotic for UTI). Another social service note, written by the social service designee (SSD), dated January 27, 2015, without a time, indicated the SSD visited the patient in her room. The SSD documented the patient was confused, stating she was a professional boxer. The note indicated Patient 2 would yell and scream due to her confusion and hallucinations. On February 9, 2015 at 11:40 a.m., during an interview, the assistant director of nurses (ADON) stated after reviewing the patient?s record, the patient did lose 30 pounds in three months, and there was no documentation in the clinical record, not on the IDT (interdisciplinary team) notes, nurses ?notes or social services? notes that the patient?s family was notified of the weight loss and change in condition, and should have been. The ADON looked at the Admission Face Sheet, and stated the patient was self-responsible, (although the physician indicated the patient did not have the capacity to make decisions). The ADON was shown the H/P, written by the patient?s physician, indicating the patient did not have the capacity to make decisions. However, the facility?s staff continued to allow the patient to make decisions about her health and well-being without intervening until the patient was chosen as a sample patient during the licensing survey and they were questioned. The medical director stated he was not aware of Patient 2?s condition and her continued refusal of medications, food, and care. On February 12, 2015 at 9:30 a.m., during a telephone interview, the facility?s medical director was asked if a confused, psychotic patient had the right to refuse life sustaining medications and treatments. The medical director stated, ?I?m glad you asked that question, because we have to be careful with patients? rights, they (the patients?) can refuse some treatments, but patients who can?t make sound decision, we should ask for them to be conserved (placed on conservatorship/legal concept where a guardian/protector is appointed by a judge to manage the financial affairs and/or daily life of another due to physical or mental limitations, or old age). It could be harmful to a patient to not receive certain medications and treatments, so we should send them to the hospital to assist us in the process.? At 10:05 a.m., on February 12, 2015, during an interview, the director of nurses (DON) was informed what the medical director had stated regarding a patient who was psychotic and confused and that they should not make healthcare decision to their detriment. The DON stated she agreed and stated Patient 2 did not have the capacity to make decisions. She stated she called an emergency IDT meeting on February 10, 2015, so they can get a bio-ethnics (moral discernment as it relates to medical policy, practice, and research) committee involved regarding Patient 2, because the patient?s family member was not responding to calls and the patient will lay in the bed and die. The DON was asked at what point the staff were going to intervene with Patient 2, who was constantly refusing medications, food, care, and had significant weight loss. The DON stated we must be more proactive and get the family, medical director, a bio-ethnic committee involved before the patient dies. On February 12, 2015, at 11:10 a.m., Patient 2?s family member, who lives out of state and does not visit, was called and a message left. However, the call was not returned by the family member. On February 13, 2015, at 1 p.m., the SSD stated she finally spoke to Patient 2?s family member, after many attempts and no return call. The social worker stated the facility would move forward with conservatorship for the patient for decision-making. The DON and administrator presented a policy, stating this will be the policy they will implement for Patient 2, titled, ?Bioethics Committee.? The policy indicated the purpose was to provide residents, families and providers with an opportunity to participate in medical decisions, discuss concerns, and obtain advice regarding ethical dilemmas that arise during the treatment of a resident. The policy further stipulated the facility would provide treatment in accordance with the resident/responsible party?s choice and make decisions in the best interest of a resident in the event the resident does not have a responsible party and is unable to participate in the decision-making process. The facility failed by: 1. Not notifying Patient 2?s family, physician, and the facility?s medical director of her deteriorating condition due to her refusal to take her life sustaining medications, eat and drink at times. 2. Allowing Patient 2, who continued to eat and drink poorly, with a substantial weight loss, to refuse without staffs? interventions after the physician documented the patient did not have the capacity to make decisions. The above violations either jointly, separately, or in any combination presented an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 970000077 |
South Pasadena Care Center |
950011334 |
B |
10-Apr-15 |
DM3W11 |
4571 |
?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 a complaint on January 23, 2015. The complaint indicated on June 8, 2014, at 1:15 p.m., two police officers went to the facility to assist Patient 14, because he believed someone had stolen two hundred dollars from him. The complaint also indicated while the police was in the facility, the patient was detained and placed on a 5150 (authorizes a qualified officer or clinician to involuntarily confine a person suspected to have a mental disorder that makes him or her a danger to themselves, to others, and/or gravely disabled) secondary to making statements that he wanted to kill himself. On February 9, 2015, at 7a.m., an unannounced complaint investigation was conducted. Based on interviews and record reviews, the facility failed to implement its policy and procedures regarding theft prevention by not: 1. Notifying the police and investigation the alleged theft 2. Reporting the alleged theft to the Department. A review of Patient 14?s medical record indicated the patient was a 38 year-old male, admitted to the facility on May 25, 2014. His diagnoses included rehabilitation (nonspecific), difficulty in walking, muscle weakness (general), anxiety state and depressive disorder.A Minimum Data Set ( MDS), an assessment and care screening tool, dated June 7, 2014, indicated the patient had no short or long term memory problems, had the ability to make his needs known, but had hallucinations (perceptual experience in the absence of real external sensory stimuli) with no behavior symptoms.On February 9, 2015, at 11 a.m., during an interview, the administrator was asked for an investigation report regarding Patient 14?s reporting his money missing/stolen. The administrator stated he did not remember the missing monies incident and would look for the report.On February 9, 2015, at approximately 1 p.m., an interview with a business office manager (BOM), who was responsible for Patient 14?s trust account, was conducted. According to the BOM, Patient 14 had a trust account that total $1,362.00 for the month of June 2014. The BOM stated the patient asked for the money and was given the sum total of $1,300.00 cash on June 5, 2014. A review of a receipt, dated June 5, 2014, indicated Patient 14 signed for the $1,300.00. A review of a police report, dated June 8, 2014, and timed at 3:18 p.m., indicated the police were dispatched to the facility, because Patient 14 was combative and trying to hit staff. When the police arrived, staff directed them to the patient who stated he was assaulting the staff because he believed that someone had stolen two hundred dollars ($200.00) from him. According to the report, Patient 14 stated the nurse?s shadow was messing with him all day and he did not want to live anymore and wanted to kill himself by jumping in front of a train. It was then the police detained Patient 14 on a 5150 and transported him to the general acute care hospital (GACH). A subsequent review of the patient?s medical record transferred/discharge summary indicated on June 9, 2015, the patient was discharged from the facility to a GACH. A review of the patient?s inventory of personal effect was not signed to indicate the patient had retrieved his belonging.A review of the facility?s theft prevention policy, revised on December 1, 2012, indicated the facility?s staff should document reports of lost and stolen resident property for items with a value of $25.00 or more and the record would be available to the Department for at least one year. The policy also indicated an investigation would be done by the administrator and the results of the investigation would be reported to outside agencies including the Department.On February 11, 2015, at approximately 11:30 a.m., during a subsequent interview, the administrator stated he did not have an investigation of the reported theft and did not report the theft to the Department as per the facility?s policy. Additionally, there was no documented evidence, on the facility?s log or the patient?s medical record, the patient had complained his money was missing.The facility failed by not: 1. Notifying the police and investigation the alleged theft 2. Reporting the alleged theft to the Department. The above violation had a direct or immediate relationship to the health, safety or security of Patient 14. |
| 970000077 |
South Pasadena Care Center |
950011335 |
B |
10-Apr-15 |
DM3W11 |
6585 |
?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 a complaint on January 23, 2015. The complaint indicated on May 20, 2014, the police received a report indicating a patient, (Patient 13) signed out of the facility on May 20, 2014, at 9:43 a.m., and never returned or contacted the facility.On February 9, 2015, at 7 a.m., an unannounced complaint investigation was conducted.Based on interviews and record reviews, the facility failed to implement its policy and procedures regarding wandering and elopement by not: 1. Reporting Patient 13?s elopement to the Department. 2. Documenting Patient 13?s elopement in the medical record. 3. Assessing Patient 13 after she returned to the facility after two days.On February 9, 2015, a review of Patient 13?s medical record indicated the patient was a 52 year-old female, admitted to the facility on April 28, 2014. Her diagnoses included rehabilitation (nonspecific), difficulty in walking, muscle weakness (general), anxiety state, and depressive disorder.A Minimum Data Set (MDS), an assessment and care screening tool, dated May 19, 2014, indicated the patient had no short or long term memory problems and had the ability to make her needs known.A physician?s order, dated May 20, 2014, and timed at 10 a.m., indicated to discharge the patient home. A review of the discharge summary, signed by an interdisciplinary team (IDT) member on May 26, 2014, indicated on May 20, 2014, the patient was discharged home with medications and a treatment plan. A review of the recapitulation of care and discharge summary guide for aftercare, signed on May 20, 2014, indicated the patient was discharged home on May 20, 2014, with medications and a follow-up appointment in one week with the patient?s primary physician. A review of the social services evaluation follow-up indicated the patient was discharged home on May 20, 2014. However, on February 9, 2015, a review of a licensed nursing note, dated May 21, 2014, and timed at 2:30 p.m., indicated Patient 13 was still out on pass on May 20, 2014. According to the note, the nurse called the patient?s family member and left a message, because the patient had not come back to the facility from being out on pass. The note indicated the family member called back at 3 p.m., and told the nurse she was out of the state and did not have the patient?s telephone number. The licensed nursing note ended with, ?will monitor.? On February 9, 2015, at 11:30 a.m., during an interview, the administrator was asked for an investigation report regarding Patient 13 not returning to the facility from being out on pass. The administrator stated he would look for the investigation. The administrator was also asked why the patient?s physician, medical records and social services documented in the patient?s medical record, the patient was discharged home. The administrator stated he would find out. On February 9, 2015, at 12 p.m., the administrator submitted an investigation report, dated February 9, 2015 (same day as survey). According to the report, Patient 13 went out on pass on May 20, 2014 to go home, however she did not come back to the facility on the same day. The report also indicated the reason social services documented the patient was discharged home was because the patient did not come back to the facility. The report indicated the patient still was not back in the facility on May 21, 2014, and on May 22, 2014, at approximately 3 p.m., the staff saw the patient near the facility?s building. The staff encouraged the patient to come back into the facility, however Patient 13 refused. At approximately 4 p.m., on May 22, 2014, the patient came back to the facility and stayed overnight. The report indicated on May 23, 2014, at approximately 10:30 a.m., the patient was discharged home with her personal belongings.At approximately 1:30 p.m., on February 9, 2015, a subsequent interview with the administrator was conducted. When he was asked why the investigation was dated February 9, 2015, he stated he had just done the investigation (nine months after the incident occurred). When asked how he conducted his investigation since the incident happened nine months ago, he stated he interviewed staff and reviewed the licensed nurse?s communication book regarding the incident. The administrator was asked if he reported the missing patient to the Department. He stated ?No.? The administrator stated he thought the patient went home. When asked why the patient?s physician wrote a discharge order the same day after the patient had gone out on pass and why the facility?s medical records documented the patient was discharged home with medications and a treatment plan, he did not answer.A review of a form titled, ?Release of Responsibility for Leave of Absence/Out on Pass,? indicated Patient 13 signed out on pass on May 20, 1024, at 9:43 a.m., with an expected return time of 4 p.m. However, the patient did not sign back in, and there was no indication the patient went home. A review of the facility?s policy, revised on December 1, 2012, and titled, ?Wandering and Elopement? indicated in response to a patient elopement the administrator or designee would contact the law enforcement, and the licensed nurse would document in the patient?s medical record how the elopement occurred and make the necessary report to the State agencies in compliance with the facility?s Unusual Occurrence Reporting policy. The policy also indicated when the individual who departed without the proper procedures, returns to the facility, the director of nursing or licensed nurses should examine the resident for any possible injuries; notify the attending physician, and the resident?s responsible party. Additionally, the patient?s care plan should be updated and the facility should implement immediate interventions to prevent another elopement. There was no evidence that any of the facility?s policies and procedures were implemented.The facility failed to implement its policy and procedures regarding wandering and elopement by not: 1. Reporting Patient 13?s elopement to the Department. 2. Documenting Patient 13?s elopement in the medical record. 3. Assessing Patient 13 after her return to the facility after two days. The above violation had a direct or immediate relationship to the health, safety or security of patients. |
| 970000077 |
South Pasadena Care Center |
950011336 |
B |
10-Apr-15 |
DM3W11 |
4594 |
?1418.91. Reports of incidents of alleged abuse or suspected abuse of residents (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class ?B? violation. The Department received a complaint alleging on January 23, 2015 at 8 p.m., there was a patient to patient abuse (Patients 11 and 12). Based on interview and record review, the facility failed to: 1. Report the abuse allegation to the Department of Health. 2. To follow its policy and procedure in reporting an abuse allegation within 24 hours. These failures of not following its reporting policy and procedures had the potential to put Patients 11 and 12, and other patients at risk for abuse. On February 9, 2015, at 3 p.m., an unannounced complaint investigation was conducted.A review of a police investigation report, dated January 17, 2014, and timed at 8:49 p.m., indicated there was an altercation between Patients 11 and 12 at Patient 11?s beside. Patient 11 accused Patient 12 of coming into her room. Patient 11 told Patient 12 ?To get out, this isn?t your room.? Patient 12 continued to enter Patient 11?s room while saying, ?This is my room.? Patient 11 got out of the bed, grabbed onto Patient 12?s wheel chair and attempted to push him out of her room. According to the report, Patient 12 struck Patient 11 on the shoulder with a closed fist. The report indicated Patient 12 was removed from Patient 11?s room by other patients who arrived after the disturbance occurred. Patient 11 stated none of the staff came to assist, so Patient 11 called the police.A review of Patient 12?s Admission Record, indicated the patient was a 72 year-old male admitted to the facility on May 10, 2013 and re-admitted on October 14, 2013. Patient 12?s admission diagnoses included, joint pain, depressive disorder (persistent feeling of sadness and loss of interest), dysphagia (difficulty in swallowing) and anxiety with mental disorder.According to the record, Patient 11, a 67-year-old female, was admitted on September 6, 2013 with diagnoses that included general muscle weakness, dysphagia (difficulty in swallowing), a mental disorder, seizure disorder (a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness) with left-sided weakness. A review of the facility?s investigation report, dated January 20, 2014, indicated on January 17, 2014, at approximately 7:45 p.m., a certified nurse assistant (CNA 3) saw Patient 12 going towards Patient 11?s room in his wheel chair wearing a lap buddy (a waist restraint). CNA 3 immediately walked towards the room to prevent Patient 12 from disturbing the room occupants, but when CNA 3 caught up with Patient 12, he was already inside Patient 11?s room and Patient 11 was heard screaming, asking for help. According to the investigation report, CNA 3 immediately wheeled Patient 12 out of Patient 11?s room and took him to the dining room. On February 11, 2015, at 3:20 p.m., during an interview, the assistant director of nursing (ADON) stated on the evening of January 17, 2014, he heard a scream coming from Patient 11?s room and immediately ran to the patient?s room to see what happened. The ADON indicated he asked Patient 11 what happened and she stated Patient 12 had hit her.On February 11, 2015, at 2 p.m., during an interview, the administrator stated he did an investigation report of the altercation, but did not report the incident to the Department. A review of the facility?s policy revised on September 1, 2013, titled, ?Reporting Abuse,? indicated under Section III. Reporting Requirements indicated; If the reportable event does not result in serious bodily injury, the administrator will make a telephone report to the local law enforcement agency within 24 hours of the knowledge of the physical abuse. In addition, a written report shall be made to the local ombudsman, the California Department of Public Health, and the local law enforcement agency within 24 hours of the knowledge of the physical abuse. The facility failed to: 1. Report the abuse allegation to the Department of Health. 2. To follow its policy and procedure in reporting an abuse allegation within 24 hours.The above violation, of not reporting the abuse allegation of Patient 11 immediately or within 24 hours, had a direct or immediate relationship to the health, safety or security of patients. |
| 970000077 |
South Pasadena Care Center |
950011337 |
B |
10-Apr-15 |
DM3W11 |
4792 |
?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. On January 29, 2015, the Department received a complaint alleging a patient (Patient 17) complained his jewelry was stolen.Based on interview and record review, the facility failed to: 1. Report the theft allegation to the Department of Public Health. 2. To follow its policy and procedure in reporting patients? theft allegation. On February 10, 2015, at 2 p.m., an unannounced complaint investigation was conducted to investigate the alleged theft incident.On October 12, 2014, at approximately 1:08 p.m., the police did an investigation into the jewelry theft. Patient 17 was interviewed by the police who provided the following information; According to a police investigation, conducted on October 12, 2014, indicated on October 11, 2014, at approximately 11:30 p.m., Patient 17 walked into his room and saw Patient 7 rummaging through his night stand. Patient 17 stated he confronted Patient 7, whom he did not know. Patient 7 told Patient 17 he thought he was in his own room and then left the room. Patient 17 stated he did not see Patient 7 take anything, but after Patient 7 left the room, Patient 17 looked in his drawer and found that his silver necklace, which he valued at approximately $1000.00, was missing. Patient 17 stated he reported this incident to the facility?s staff, but when nothing was done he called the police.A review of Patient 17?s admission record indicated the patient was a 56 year-old male who was re-admitted to the facility on June 9, 2014, with the following diagnoses, muscle weakness, angina pectoris (a severe pain and sensation of constriction of the heart), glaucoma (pressure build up inside the eye, placing pressure on the optic nerve), mood disorder and a mental disorder. A review of Patient 7?s admission record indicated he was a 52 year-old male who was re-admitted to the facility on June 19, 2013. His diagnoses included dementia with psychosis (a mental disorder involving a loss of contact with reality), diabetes mellitus (failure of the pancreas to breakdown sugar), anxiety, renal insufficiency (kidneys not working properly) and a mental disorder. A review of Patient 17?s inventory of personal effects record, dated August 8, 2014, included and listed a necklace with a cross. A review of the facility?s Theft /Loss and Grievance Report, dated October 13, 2014, indicated under the section listed as ?Description of concern/theft/loss? on October 11, 2014, the theft loss grievance report indicated Patient 17 stated he had a silver chain with a cross. Patient 17 stated when he looked into his drawer he saw the cross was left. Patient 17 stated this incident happened approximately between 9:30 p.m.-10 p.m. Patient 17 stated the estimate value of his necklace was approximately $1000.00. The theft report indicated two nurses searched three different times, which included both the patient?s personal belongings. According to the theft report, Patient 17 was not satisfied with the outcome of the investigation, so the next day he filed a police report. However, Patient 17 agreed to accept $100.00 from the facility to replace his loss. The theft report was signed by the administrator and the social service designee. On February 10, 2015, at 2:20 p.m., during an interview, the administrator stated an investigation report was done and the staff looked for the patient?s necklace, but they could not find it. The administrator stated he offered the patient $100.00 for the value of the necklace and the patient agreed and accepted the $100.00. The administrator stated because the patient accepted the money for the replacement of the silver necklace, he did not report the patient?s theft to the Department. However, a review of the facility?s policy, revised on September 1, 2012, titled ?Theft Prevention? under Section II. Measures to Secure Personal Property; indicated the following: F. The administrator would report the results of the investigation to the local police department, the ombudsman and to the Department of Public Health in a timely manner. It also stipulated that the facility documents reports of lost and stolen residents? property on AP-11-form C- Lost and Stolen Property Log for items with a value of twenty-five ($25) dollars or more of particular value to the patient.The facility failed to: 1. Report the theft allegation to the Department of Public Health. 2. To follow its policy and procedure in reporting patients? theft allegation. The above violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 970000077 |
South Pasadena Care Center |
950011338 |
B |
10-Apr-15 |
DM3W11 |
5038 |
?1418.91. Reports of incidents of alleged abuse or suspected abuse of residents. (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class ?B? violation. On January 29, 2015, the Department received a complaint alleging a patient (Patient 15) to patient (Patient16) abuse. Patient 16 grabbed and pushed Patient 15 around and attempted to strike him in the face in front of other patients on the facility?s patio during a smoke break. Patient 15 called the police. Based on interview and record review, the facility failed to: 1. Report the abuse allegation to the Department of Health. 2. To follow its policy and procedure in reporting an abuse allegation. On February 10, 2015 at 1:30 p.m., an unannounced complaint investigation was conducted to investigate the alleged abuse between Patients 15 and 16. On October 22, 2014, at approximately 7:45 p.m., there was an altercation between Patient 15 and Patient 16. Patient 15 was accused of stealing Patient 16?s hat and Patient 16 grabbed Patient 15 by the shirt collar and suddenly shook him.A review of Patient 15?s admission record indicated the patient was a 49 year-old male who was admitted to the facility on October 7, 2013 from home. The admission diagnosis was hypertension (high blood pressure). On February 10, 2015 at 1:45 p.m., a review of Patient 16?s admission record indicated he was a 53 year-old male admitted to the facility on September 22, 2014, from another skilled nursing facility. The admission diagnoses included depressive disorder (a persistent feeling of sadness and loss of interest) ddepressive anger with insomnia (inability to sleep at night) and a mental disorder. A review of the facility?s investigation report, dated October 28, 2014, indicated on October 22, 2014, at approximately 7:45 p.m., an altercation occurred between Patients 15 and 16. The staff immediately intervened and separated the two patients. The physicians for both patients were notified, both patients were assessed by the licensed nurse and no injuries were identified, no redness, no discoloration, no pain, and no skin breakdown. Patient 16 was taken back to his room and offered Ativan (antianxiety medication), but refused three times. According to the investigation report, the nurses implemented a one-on-one monitoring for Patient 16 for safety until the patient was sent to the general acute care hospital (GACH). Patient 16 was transferred to another room, further away from Patient 15?s room. Patient 15 was informed of the mistaken identity by Patient 16. On February 10, 2015, at 1:45 p.m., a review of the Charge Nurse Assessment note written on October 22, 2014, and timed at 8:30 p.m., indicated Patient 16 was alert, verbally responsive and denied any pain or discomfort. The note further indicated on October 22, 2014, at 7:45 p.m., ?Code Orange? (meaning patient has a behavior problem and staff must respond immediately) was paged overhead to the patio area, immediately the staff rushed to the patio and separated both patients. Patient 16 replied, ?Some people told me Patient 15 from another room stole my belongings. I approached him and put my hand on his shirt.?The assessment note indicated the following information on October 22, 2014: At 7:55 p.m., the physician was notified and gave an order to monitor Patient 16?s behavior. At 9:30 p.m., Patient 16 was given Ativan medication and his room was changed. On October 23, 2014, Patient 16 was discharged to the GACH due to being a danger to others. On February 10, 2015, at 2 p.m., during an interview, the administrator stated the investigation report of the patient-to-patient altercation was sent to the ombudsman office. At 2:30 p.m., on February 10, 2015, during a subsequent interview, the administrator stated the police was called by Patient 15. The administrator stated he did not notify the Department of Public Health of the incident. A review of the facility?s policy revised on September 1, 2013, titled, ?Reporting Abuse,? indicated under Section III. Reporting Requirements; If the reportable event does not result in serious bodily injury, the administrator will make a telephone report to the local law enforcement agency within 24 hours of the knowledge of a physical abuse. In addition, a written report shall be made to the local ombudsman, the California Department of Public Health, and the local law enforcement agency within 24 hours of the knowledge of the physical abuse. The facility failed: 1. Report the abuse allegation to the Department of Health. 2. To follow its policy and procedure in reporting an abuse allegation. The above violation, of not reporting the abuse allegation of Patients 15 and 16 immediately or within 24 hours had a direct or immediate relationship to the health, safety or security of patients. |
| 970000077 |
South Pasadena Care Center |
950011349 |
B |
10-Apr-15 |
DM3W11 |
9096 |
?72351. Dietetic Service-Staff. (a) A dietitian shall be employed on a full-time, part-time or consulting basis. Part-time or consultant services shall be provided on the premises at appropriate times on a regularly scheduled basis. A written record of the frequency, nature and duration of the consultant?s visits shall be maintained. Based on interview and record review, the facility staff failed Patient 2, who had a significant weight loss of 16.4% in three months, Stage IV pressure ulcer (Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures [e.g., tendon, joint capsule]) and difficulty in swallowing (dysphagia) by: 1. The registered dietician (RD) not evaluating the patient?s nutritional needs, assessing, documenting and reporting the findings monthly as stipulated in the RD?s job description and reporting. 2. The RD not actively participating in the care of Patient 2, as it relates to dietary. 3. Allowing the dietary service supervisor (DSS) to work beyond her scope of practice by evaluating Patient 2.These failures had the potential of Patient 2 to choke on food due to the lack of an ongoing assessment of food intake and textures needed, continue to lose weight, and pressure ulcer getting worse.During a licensing visit, a review of Patient 2's Admission Face Sheet indicated the patient was admitted to the facility on October 6, 2011 and re-admitted on September 30, 2014. The patient's diagnoses included a Stage IV pressure ulcer (on the buttocks, requiring an indwelling urinary catheter for wound management, atrial fibrillation (most common abnormal heart rhythm), dysphagia (difficulty in swallowing) and hyperlipidemia (involves abnormally elevated levels of any or all lipids and/or lipoproteins in the blood [fats]). A Minimum Data Set (MDS), an assessment and care screening tool, with a reference date of January 31, 2015, indicated Patient 2 had the ability to understand and be understood, but was unable to identify the day, year, or month. According to the MDS, Patient 2 was non-ambulatory and required extensive assistance to being totally dependent upon staff for care, which included turning and repositioning. The patient was always incontinent (inability to control) of bowel and had an indwelling urinary catheter in place for urination for wound management. A review of the "Braden Scale-for predicting pressure sore risk," initiated on September 30, 2014, and last reviewed on October 21, 2014; indicated Patient 2 had a score of 10. According to the scale, a total score of 12 or less represents HIGH RISK. A care plan, dated September 30, 2014 and last updated December 2014, titled, ?Risk for developing pressure sore, bruising, and other types of skin breakdown related to the patient's history of skin alterations, reduced mobility and incontinence of bowel and bladder. The patient's goal was to minimize the risk of skin breakdown/pressure sores by 90 days. The staff's plan of approaches included turning and repositioning in bed and chair, using pressure relieving devices, providing treatments as ordered and monitoring for signs of pain and discomfort and medicate as ordered. Another care plan, dated October 7, 2014, and updated on January 2015, titled, "Altered Nutrition and Hydration Status," indicated the patient was at risk for weight loss and dehydration (more fluid excreted from body than taken in) due to poor appetite and dysphagia (difficulty in swallowing).The goals included indicated the patient would be free from significant weight loss of 5% or greater for a month, with an intake of 90% of food intake and evidence of good hydration. Under staff's plan of approach, the RD to assess nutrition and hydration status as needed was not checked. A review of a ?Follow-up Weight Review," dated November 6, 2014, indicated Patient 2 had poor meal intolerances due to distraction and throwing food. The planned interventions included; providing between meal snacks and an appetite stimulant (Megace), in which the patient refused to take.A review of a ?Monthly Record of V/S [vital signs] & WTS [weights] ?indicated Patient 2 weighed 152 pounds (lbs.) in September and October 2014, in November 2014, the patient weighed 135 pounds, a 17 pound weight loss; December 2014 the patient weighed 132, another 5 lbs. weight loss; January 2015, Patient 2 weighed 127 pounds with another 5 pounds lost; and February 2015, the patient lost another 5 pounds, weighing only 122 pounds. A review of a dietary progress record, dated November 13, 2014, and timed at 1:30 p.m., written by the dietary supervisor (DSS) that was not clearly legible and not countersigned by the RD. Another note, written by the DSS, titled, "Quarterly Nutritional Progress note, dated January 29, 2015, indicated the patient weighed 127 pounds, a 16.4 % weight loss in 3 months. The patient's albumin level was low at 3.0 (normal reference range= 3.4-5.4 grams per deciliter [g/dL]). Low albumin is a warning and an indication that further investigation may be warranted and can be seen in patients with inflammation (process by which the body's white blood cells and substances they produce protect us from infection with foreign organisms), shock (a medical emergency in which the organs and tissues of the body are not receiving an adequate flow of blood), and malnutrition (lack of proper nutrition).On February 11, 2015 at 8:40 a.m., during the patient's wound care observation, with LVN 1, the large deep sacral wound, measured 7 by 5.5 centimeters (cm) in size and 1.5 cm in depth. The sacral wound had bloody drainage with some slough (necrotic tissue in the process of separating from viable portions of the body; to shed or cast off) and some muscle and bone was visible.On February 13, 2015, at 8:40 a.m., during an interview, the assistant director of nurses (ADON) was asked how often the RD visits the patients, he initially hesitated, and then stated, "Once or twice a month." He was asked which patient does the RD see and he stated the patients who gains or loses weight. He was presented Patient 2's clinical record to review the dietary notes and stated the last RD note was written October 16, 2014, and all the other notes and assessment were written by the DSS. The RD was called on February 13, 2015 at 9:16 a.m., and a message was left. The RD called back on February 13, 2014 at 12:55 p.m., she was asked about Patient 2 and she stated she was familiar with the patient. The RD stated she may have not written notes, but she was very familiar with the patient. At 11:20 a.m., on February 13, 2015, during an interview, the DSS stated she was not able to decipher the note written on November 13, 2014 and February 10, 2015. She stated after reviewing all the dietary notes, the RD did not write a note in December 2014 and January 2015. The DSS stated she did assess and write the notes on the patient?s record. The DSS stated the RD should see patients every month who have weight loss or gain, new admissions, and patients with pressure ulcers. A review of the Business and Professional Code Section 2586 (a)(1) indicated notwithstanding any other provision of law, a registered dietitian, or other nutritional professional meeting the qualifications set forth in subdivision (e) of Section 2585 may, upon referral by a health care provider authorized to prescribe dietary treatments, provide nutritional and dietary counseling, conduct nutritional and dietary assessments, and develop nutritional dietary treatments. Under Section 2586 (d)(1) indicated the dietetic technician, under the direct supervision only (physically available) can assist in implementation or monitoring of services, but may not develop dietary therapy or treatments for patients.A review of the facility's job description for the RD, titled, ?Orientation, In-service, & Personnel Management," indicated the dietary consultant provides consultation to the facility for the purpose of providing nutritional care and oversight, which will result in optimal health of the resident/patients. Under Responsibility, indicated the RD responsibilities included evaluating the patient's nutritional needs, documenting recommendations in the record and reporting concerns and findings monthly. Reviewing and assisting the dietary service supervisor (DSS) in interdisciplinary care planning and dietary care plans. Also advising and counseling the DSS in all areas of food service and nutritional care.The facility failed by:1. The registered dietician (RD) not evaluating the patient?s nutritional needs, assessing, documenting, and reporting the findings monthly as stipulated in the RD?s job description. 2. The RD not actively participating in the care of Patient 2, as it relates to dietary. 3. Allowing the DSS to work beyond her scope of practice by evaluating Patient 2.The above violation had a direct or immediate relationship to the health, safety, or security of Patient 2. |
| 970000077 |
South Pasadena Care Center |
950011350 |
B |
10-Apr-15 |
DM3W11 |
6448 |
?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 a complaint alleging two patients (Patients 1 and 9) were arguing and verbally abusing each other on October 11, 2014. Patient 1 was heard by staff and other patients to have stated ?If you keep it up, I?m going to put a bullet in you.? Patient 9 expressed fear, because Patient 1 was known to carry a handgun in his electric wheelchair. An announced complaint investigation was conducted on February 9, 2015.Based on interviews and record reviews, the facility failed by not: 1. Following its policy and procedures. 2. Reporting the allegation to the Department. 3. Conducting an investigation to ensure the safety of Patient 9 and other patients in the facility. These failures resulted in Patient 9 feeling fearful and nervous and had the potential to result in harm to Patient 9 and other patients in the facility. A review of Patient 1?s Admission Face Sheet indicated the patient was a 53 year-old male admitted to the facility on November 6, 2011. The patient?s diagnoses included Stage IV buttocks pressure ulcer, intestinal obstruction, paraplegia (an impairment in motor or sensory function of the lower extremities) status-post gunshot wound, and chronic pain syndrome (ongoing pain lasting longer than 6 months). A review of the physician?s recapped order, dated November 23, 2013, indicated Morphine Sulfate 60 milligram (mg) to be given orally (by mouth) every 12 hours (9 a.m. and 9 p.m.) for severe pain. A review of a Minimum Data Set (MDS), an assessment and care screening tool, with an assessment date of November 21, 2014, indicated the patient had the ability to understand, be understood and for recall. According to the MDS, Patient 1 was non ambulatory (paraplegic), but required only minimal assistance with bed mobility, dressing, and transferring. The patient used an electric wheelchair for locomotion. The MDS, under Section E/Behavior indicated the patient exhibited verbally threatening, cursing and screaming behavior at others. During the investigation, several attempts were made to interview Patient 1, but he became hostile and attempted to run the evaluator over with his wheelchair. A review of Patient 9?s Admission Face Sheet indicated the patient was a 51 year-old male who was admitted to the facility on February 18, 2012 and discharged on November 17, 2014. The patient?s diagnoses included congestive heart failure (CHF/ condition in which the heart's function as a pump is inadequate to meet the body's needs), anemia (condition that develops when blood lacks enough healthy red blood cells or hemoglobin [hemoglobin is the main part of red blood cells used for oxygenation of the body?s cells]), and esophageal reflux (condition in which the stomach contents leaks backwards from the stomach into the esophagus [the tube from the mouth to the stomach]).A review of a MDS with a reference date of October 11, 2014, indicated Patient 9 had the ability to understand and be understood with the ability to recall. The patient required limited assistance, of a one-person assist with his activities of daily living. According to the MDS, Patient 9 had no behavior problems. A review of a nurse?s note, dated October 14, 2014, three days after the incident, without a time, indicated Patient 9 approached the Interdisciplinary team ([IDT]/administrator, DON and nurse consultant) and stated he felt threatened by another patient (Patient 1). Patient 9 stated the other patient informed him, ?I will kill you and I have a gun? while calling him names. Patient 9 told the IDT team that Patient 1 has guns and knives in his possession. According to the nurse?s note, the police were called and a search of Patient 1?s room was conducted. Another nurse?s note, dated October 15, 2014, four days after the incident, and timed at 11 p.m.-7a.m. shift, indicated Patient 9 continued to express fear about Patient 1 hurting him stating, ?I am scared, nervous and jumpy.? A review of the police report, dated October 14, 2014, indicated the police arrived to the facility at 11:13 a.m., to investigate the patient to patient altercation. The police report indicated Patient 9 told the police he feared for his life because Patient 1 threatened to put a bullet in his head. Patient 9 further informed the officer that Patient 1 produced a box cutter and threaten to cut him. On February 11, 2015, at 1:27 p.m., during an interview, the administrator stated an investigation was not conducted and the incident was not reported to the Department as indicated in the facility?s policy.At 9 a.m., on February 12, 2015, the assistant director of nurses (ADON), during a concurrent interview and record review, stated Patient 9 was afraid of Patient 1. After reviewing the record, the ADON stated a care plan should have been initiated and implemented to address Patient 1?s fear and to re-assure the patient of his safety. The ADON also indicated the incident should have been reported to the Department as well. On February 12, 2015, at 4 p.m., an interview was conducted with the alleged witness (Patient 18) to the altercation. Patient 18, who was alert and able to make needs known, according to her MDS, stated she did not witness the altercation, but heard from other patients that Patient 1 was threatening Patient 9 with a gun. Patient 18 stated Patient 1 was known to be aggressive to others. A review of the facility?s policy titled, ?Reporting Abuse? indicated if an allegation included patient-patient, the patients would be separated pending an investigation. The policy also stipulated a suspected abuse, other than physical shall also be reported to the Ombudsman, local law enforcement and the Department of Public health within 24 hours. The policy, under Investigation Results, stipulated an investigation result would be provided as a written report within five days. The facility failed by not: 1. Following its policy and procedures. 2. Reporting the allegation to the Department. 3. Conducting an investigation to ensure the safety of Patient 9 and other patients in the facility. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 9 and other patients in the facility. |
| 970000077 |
South Pasadena Care Center |
950011366 |
B |
10-Apr-15 |
DM3W11 |
4561 |
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. Based on interview and record review, the facility failed to: Report an alleged abuse involving a facility employee who pushed Patient 21 three times causing him to fall onto a couch.On February 11, 2015, at 8:30 a.m., an announced visit was conducted at the facility to investigate a complaint regarding Employee to Resident Abuse involving Patient 21. A review of Patient 21's Face Sheet indicated the patient was admitted to the facility on February 20, 2014, with diagnoses that included spinal stenosis (narrowing of the open spaced within the spine), bipolar disorder (a disorder associated with mood swings ranging from depressive lows to manic highs), and anxiety state. According to the Face Sheet, the patient was discharged to the acute hospital on March 5, 2014. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated February 27, 2014, indicated the resident was able to complete the brief mental status interview, understands others and able to make himself understood, and required limited assistance with most activities of daily living. A review of a police report dated March 3, 2014, indicated a report was received regarding a security guard (Employee A) who assaulted a patient (Patient 21) at the facility. The report indicated Patient 21 stated that Employee A pushed him backwards three times which caused him to fall onto a couch on the third push. According to the report, there was no injury but the patient wanted to file charges. Further review of the police report indicated there was insufficient evidence that Employee A committed battery on the victim.During a telephone interview on February 11, 2015, at 11:40 a.m., Employee A stated that Patient 21 wanted to go out on pass, but did not have a physician's order to leave the facility. Employee A stated he attempted to talk to the patient and convince him to stay, but the patient refused to listen and became loud and verbally aggressive. According to Employee A, he continued talking to the patient until the patient calmed down. Employee A denied ever touching or pushing Patient 21. During an interview on February 11, 2015, at 2:40 p.m., the Administrator stated that the alleged abuse was not thoroughly investigated and reported to the department, because the previous director of nursing (DON) and registered nurse supervisor were there to witness that Employee A did not push Patient 21.During an interview on February 12, 2015, at 9:05 a.m., Patient 27, a possible witness, stated that she was with Patient 21 during the time of the incident. According to Patient 27, Employee A "shoved" Patient 21 causing him to fall on the couch. Patient 27 further stated that the facility staff lied to the police officer and told the police officer this incident did not happen. A review of Patient 27?s Face Sheet indicated the patient was admitted to the facility on November 27, 2013, with diagnoses that included asthma, depressive disorder, and schizophrenia.A review of the facility's policy and procedure titled "Reporting Abuse," dated September 1, 2013, indicated upon an allegation of abuse by a facility staff member, the facility will report known or suspected instances of physical abuse to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations. The policy further indicated if the reportable event does not result in serious bodily injury, the Administrator, will make a telephone report to the local law enforcement agency within 24 hours of the observation, knowledge, or suspicion of physical abuse. In addition, a written report shall be made to the local Ombudsman, the California Department of Public Health, and the local law enforcement agency within 24 hours of the observation, knowledge, or suspicion of the physical abuse. The Administrator shall provide the appropriate agencies with a written report of the findings of the investigation within five working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken and documented.The facility failed to: Report an alleged abuse involving a facility employee who pushed Patient 21 three times causing him to fall onto a couch.The above violation had a direct relationship to the health, safety, or security of patients. |
| 970000077 |
South Pasadena Care Center |
950011367 |
B |
10-Apr-15 |
3MWO11 |
4640 |
F309 ? 483.25 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. On 5/14/14, at 7:51 a.m., an unannounced visit was made to the facility to conduct the annual recertification survey.The facility failed to handle Resident 1 gently and carefully during the provision of patient care in accordance with the plan of care that resulted in pain and injury of the resident?s left knee. Resident 1 was admitted to the facility on 2/25/13 with diagnoses that included fracture of the low end of the left femur muscle weakness, diabetes mellitus, diabetic and osteoporosis. The plan of care indicated the resident has been on pain management since her admission to the facility for the post femur (thigh bone) fracture (broken). The pain management included the narcotic medication Norco (opioid analgesic=hydrocodone barbiturate and acetaminophen) 5/325 mg one tablet every six hours as needed for moderate (4/10 to 6/10) pain, or two tablets every six hours as needed for severe (7/10 to 10/10) pain. The MDS assessment dated 3/3/14 indicated the resident was alert and oriented and was able to make her needs known. The MDS also indicated the resident required assistance with daily activities, such as transfers and personal hygiene/bathing. During the initial tour of the facility on 5/12/14, at 8:25 a.m., Resident 1 was observed in bed. During an interview, she stated that about a week ago (5/8/15), her left knee got injured while being transferred by staff from her bed to the wheelchair with the use of a mechanical lift. The left knee was observed bigger than the right. She stated that since the injury, she has been experiencing occasional pain on the left knee and that she takes medications to help relieve the pain. She indicated the pain intensity is usually moderate to severe pain.A review of the routine medication administration record indicated on 5/9/14 (a day after the incident) the resident was given Norco 5/325 mg. 2 tablets for severe pain (7/10). There was no indication whether or not the medication was effective after it was administered. On 5/12/14, Norco 5/325 mg. 2 tablets were given for severe pain. On 5/13/14, Norco 5/325 mg. 2 tablets were given for severe pain. The medicine was administered twice that same date. On 5/16/14, 5/17/14, and 5/19/19, Norco was signed off as given for moderate pain (6/10). On 5/18/14, Norco 5/325 mg, was signed off as given twice that same date for severe pain (7/10). During an interview on 5/16/14, at 9:14 a.m., CNA 6 stated that during the transfer using the Hoyer lift (mechanical lift), CNA 6 observed that the resident's legs were crossed. CNA 6, then, uncrossed the Resident 6's legs while the resident was in mid-air. The resident, then, yelled at her not to touch her legs because she had pain. CNA 6 concurred that uncrossing the resident's leg could have put a strain on the resident's left knee, which could have caused the swelling and pain. She also stated that the resident did not complain of pain prior to the transfer. CNA 6 added this was the first time in a long time (months or years ago) that she had been assigned back to Resident 1.During an interview on 5/16/14, at 10 a.m., CNA 13 stated that she was the usual staff assigned to the resident (for over 6 years), and that she was not at work when the incident happened. She stated that the resident's lower extremities were very delicate and stiff and require a lot of care and caution during transfers, in order to prevent injuries. She stated that she was aware of the resident's natural tendency to cross her legs and that she never uncrossed them during transfers, because by doing so it would be uncomfortable for the resident. CNA 13 stated she only uncrossed them when the resident was already in the wheelchair, before placing them on the footrests.Resident 1?s plan of care dated 2/25/13 indicated the resident was at risk for:Sudden acute pain to any extremity Swelling and tenderness Guarded movement on affected area. Patient Care Goals included: Reduce risk of pain daily.Approaches and Plan included: Handle gently and carefully during care. The facility failed to handle Resident 1 gently and carefully during the provision of patient care in accordance with the plan of ca that resulted to pain and injury of the affected extremity (left knee). The above violation had a direct relationship to the health, safety or security of residents. |
| 970000077 |
South Pasadena Care Center |
950011368 |
B |
10-Apr-15 |
DM3W11 |
4591 |
Title 22 Section 72521(a) Written administrative, management and personnel policies shall be established and implemented to govern the administration and management of the facility. The facility failed to thoroughly investigate Patient 21's allegation of physical abuse by Employee A. On February 11, 2015, at 8:30 a.m., an announced visit was conducted at the facility to investigate a complaint regarding Employee to Resident Abuse involving Patient 21. A review of Patient 21's Face Sheet indicated the patient was admitted to the facility on February 20, 2014, with diagnoses that included spinal stenosis (narrowing of the open spaces within the spine), bipolar disorder (a disorder associated with mood swings ranging from depressive lows to manic highs), and anxiety state. According to the Face Sheet, the patient was discharged to the acute hospital on March 5, 2014. The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated February 27, 2014, indicated the resident was able to complete the brief mental status interview, understands others and able to make himself understood, and required limited assistance with most activities of daily living. A review of a police report dated March 3, 2014, indicated a report was received regarding a security guard (Employee A) who assaulted a patient (Patient 21) at the facility. The report indicated Patient 21 stated that Employee A pushed him backwards three times which caused him to fall onto a couch on the third push. According to the report, there was no injury but the patient wanted to file charges. Further review of the police report indicated there was insufficient evidence that Employee A committed battery on the victim.During a telephone interview on February 11, 2015, at 11:40 a.m., Employee A stated that Patient 21 wanted to go out on pass, but did not have a physician's order to leave the facility. Employee A stated he attempted to talk to the patient and convince him to stay, but the patient refused to listen and became loud and verbally aggressive. According to Employee A, he continued talking to the patient until the patient calmed down. Employee A denied ever touching or pushing Patient 21. During an interview on February 11, 2015, at 2:40 p.m., the administrator stated that the alleged abuse was not thoroughly investigated and reported to the department, because the previous director of nursing (DON) and registered nurse (RN) supervisor were there to witness that Employee A did not push Patient 21. When asked for an investigation report, the administrator could not provide documented evidence of the incident and interviews with staff members and other witnesses.However, during an interview on February 12, 2015, at 9:05 a.m., Patient 27, stated that she was with Patient 21 during the time of the incident. According to Patient 27, Employee A "shoved" Patient 21 causing him to fall on the couch. Patient 27 further stated that the facility staff (previous director of nursing (DON) lied to the police officer and told the police officer this incident did not happen. A review of Patient 27?s Face Sheet indicated the patient was admitted to the facility on November 27, 2013, with diagnoses that included asthma, depressive disorder, and schizophrenia. During a telephone interview on March 26, 2015, at 8:24 a.m., Licensed Vocational Nurse (LVN) 6 stated that Patient 27 is alert and oriented and had no history of telling lies on others and fabricating stories. The facility policy and procedure titled "Incident Investigation" dated August 1, 2014, indicated the facility will have a licensed nurse fill out the Incident Log to track and minimize the number of incidents that take place in the facility. An incident includes but is not limited to the following: falls, abuse, unusual occurrence, bruises, medication error, missing person, property loss, and respiratory arrest. In the event of an incident, a licensed nurse who first encounters or witnesses an incident will complete the Incident/Accident Report Form and document the following information on the Incident Log: resident name, day and shift during which the incident occurred, type code, injury code, location code, severity code, and medication/treatment code. As appropriate, interviews with staff members and other witnesses will be documented on the Interview Record.The facility failed to: Thoroughly investigate Patient 21's allegation of physical abuse by Employee A. The above violation had a direct relationship to the health, safety, or security of patients. |
| 970000077 |
South Pasadena Care Center |
950011370 |
B |
10-Apr-15 |
C15011 |
3864 |
Health & Safety Code 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a patient of the facility to the department immediately, or within 24 hours. The facility failed to immediately report an allegation of Staff to Patient mistreatment to prevent further mistreatment to Patient 1. As a result, Patient 1 had multiple verbal confrontations (angry face to face interactions) with CNA 2, after Patient 1 had reported the allegation of mistreatment to CNA 1. CNA 1 failed to immediately report the allegation to the administrator in accordance to the facility policy and procedure. A review of the facility's policy and procedure titled, "Reporting Abuse" dated 2/1/13, indicated the reporting requirements for the facility is to report known physical abuse to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations. Furthermore, a written report shall be made to the California Department of Public Health within 24 hours of the observation, knowledge, or suspicion of the physical abuse. The facility did not follow the policy as indicated. On 11/19/14, at 8:48 a.m., during an interview with Patient 1, he stated the incident was reported to the certified nursing assistant (CNA) 1 and no actions were taken. Patient 1 added, early in the month of 11/14, he reported to CNA 1 that CNA 2 was rough to Patient 2, his roommate, when removing Patient 2?s pants. Patient 1 confronted CNA 2 and told him he needed to treat the patients with respect. Patient 1 further stated, he felt the lack of response from the facility to remove CNA 2 from providing care to Patient 2 resulted in a second confrontation. On 11/18/14, Patient 1 had another verbal confrontation with CNA 2, who verbally threatened him; by saying he could kill the patient (Patient 1) by using his hands. At the time of the interview with Patient 1 on 11/19/14 at 8:48 a.m., CNA 1 entered the patient?s room and verified the patient had reported the incident to her either on 11/11/14 or 11/12/14. CNA 1 further stated she reported the alleged mistreatment to the CNA team leader on either of those days. A review of the CNA team leader schedule verified the staff was at the facility on 11/11/14 and 11/12/14. The CNA team leader has been on family leave since 11/13/14, and was not interviewed. During an interview with the director of staff development (DSD) on 11/19/14 at 9:09 a.m., when asked if the allegation was reported to her, she stated no. The DSD further stated when an allegation of mistreatment is made it is the facility's responsibility to remove the CNA from caring for the patient and investigate the allegation. During an interview with the administrator, on 11/19/14, at 9:30 a.m., when asked if he was aware of the allegation, the administrator responded, the incident was not reported to him. Patient 1 reported to CNA 1 the alleged mistreatment either on 11/11/14 or 11/12/14. In turn, CNA 1 reported the allegation to her team leader, who failed to report the allegation to the administrator. CNA 2 continued to be assigned to Patient1 until 11/19/14, when the surveyor notified the administrator of the allegation. The administrator stated he will start the investigation of the allegation and reported the allegation to the Department. The facility staff failed to report an alleged mistreatment of CNA 2 to Patient 1 to the facility administrator on 11/11/14 or 11/12/14. As a result, the allegation was not reported to the Department until 11/19/14, 7 days later which resulted to Patient 1?s verbal confrontations (angry face to face interactions) with CNA 2, when Patient 1 had reported the allegation of mistreatment to CNA 1. These violations had a direct relationship to the health, safety and security of reside |
| 970000077 |
South Pasadena Care Center |
950011371 |
A |
17-Apr-15 |
DM3W11 |
13290 |
Title 22 Division 5 Chapter 3 Article 3- 72311 (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. The facility failed to: 1. Do an initial and continued assessment of Patient 6?s medical need of the indwelling urinary catheter. 2. Assess the characteristics of Patient 6?s urine, such as color, clarity, and odor for signs of infection. 3. Follow its catheter management interventions to prevent urinary tract infections (UTIs) for Patient 6. 4. Follow its policy related to indwelling catheter use, by not ensuring Patient 6?s urinary catheter was medically indicated. As a result of these failures, Patient 6, who had a history of urinary tract infections (UTIs), had an indwelling urinary catheter (a flexible plastic tube used to drain urine from your bladder when a person cannot urinate by themselves) for over seven months after admission without any medical indication for its use, which resulted in three recurrent UTIs within four months of admission, on June 25, 2014, August 6, 2014, and October 6, 2014 and a newly diagnosed UTI after the abnormal urine characteristics was brought to the staff?s attention on February 9, 2015. All the UTIs required antibiotics for seven days to treat the infections, the UTI in October 2014 had two organisms identified and required an intravenous ([IV] directly into the vein) antibiotic for treatment. The recurrent UTIs put Patient 6 at risk for developing urosepsis (a condition where UTI spreads from the urinary tract to the bloodstream, causing a life-threatening infection). On February 9, 2015, at 8:08 a.m., during the facility?s initial tour, accompanied by a licensed vocational nurse (LVN 3), Patient 6 was observed sitting in a wheelchair preparing to go to activities. The patient had an indwelling urinary catheter draining cloudy urine with moderate amount of sediment (small particles floating in the urine).A review of an Admission Face Sheet, indicated Patient 6 was a 64 year-old female, who was admitted to the facility from a general acute care hospital (GACH) on June 10, 2014. Her diagnoses included hypertension (high blood pressure), muscle weakness, and diabetes (high blood sugar). A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated December 15, 2014, indicated Patient 6's cognitive skills for daily decision-making were intact. Patient 6 required extensive assistance with all activities of daily living. According to the MDS, under Section I/Active Diagnoses, neurogenic bladder was not identified as one the patient?s diagnoses. A review of Patient 6?s Bowel and Bladder Assessment, dated June 10, 2014, indicated the patient had an indwelling catheter related to a diagnosis of neurogenic bladder (problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition).According to an article by Urology Care Health, dated for spring 2014, defined a neurogenic bladder as a name given to a number of urinary conditions, which is a result of problems with nerves in the body that may control how the bladder stores or empties urine. The article indicated the various ways to diagnose neurogenic bladder, such as; a bladder scan (can show how much urine is still in the bladder after urinating), cystoscopy (insertion of a narrow tube with tiny kens into the bladder) and urodynamic test (a test to check to see how well the lower urinary tract stores and releases urine). The article further indicated the physician may need to do additional imaging tests, such as x-rays and CT scans (computerized tomography scan/ combines a series of x-ray images taken from different angles and uses computer processing to create cross-sectional images) to diagnose a patient?s condition and or referred to a specialist for an exam that may include imaging tests of the spine and brain. There was no evidence in Patient 6?s clinical record to indicate the patient had any of these procedures performed or was seen by an urologist (a physician who has specialized knowledge and skill regarding problems of the male and female urinary tract and the male reproductive organs) to diagnose the patient as having a neurogenic bladder. The GACH?s Physician Discharge Report, dated June 10, 2014, indicated the patient was discharged to the skilled nursing facility (SNF) with an indwelling urinary catheter. Patient 6?s principal diagnosis while in the GACH was pyelonephritis (a type of urinary tract infection (UTI) that affects one or both kidneys) and there was no documented evidence the patient had a diagnosis of neurogenic bladder while in the GACH. Upon admission to the SNF there was no documented evidence the patient was assessed for the continued need of the indwelling urinary catheter.A review of a nurse?s note, dated August 28, 2014, and timed on the 11-7 a.m. shift, indicated the patient?s urinary catheter had been discontinued and the patient was urinating freely in the diaper without pain or hematuria (blood in the urine). Another nurse?s note, dated August 29, 2014, and timed at 1 p.m., indicated the patient ?was unable to keep on schedule with bladder training and was noted to have incontinence (involuntary urination, is any leakage of urine) during the training,? so the physician was called and the urinary catheter was re-inserted. According to MedlinePlus, an article titled, ?Catheter-related UTI,? indicated when a patient has an indwelling urinary catheter, the patient is more likely to develop a urinary tract infection in the bladder or kidneys. It also indicated UTIs related to catheters can be harder to treat than other UTIs. A review of the patient?s plans of care indicated there was no care plan to address the patient?s medical necessity for the urinary catheter and/or risk of developing UTIs, which would include the staff approaches to monitor the urine characteristics, until the abnormal urine characteristic was observed on the survey initial tour and brought to the staff?s attention on February 9, 2015.A review of the Patient 6?s diagnostic laboratory reports, dated June 25, 2014, indicated the urinalysis (UA) and culture and sensitivity ([C/S] a set of tests performed on a clinical specimen, where isolation of a potentially pathogenic bacterium is followed by antibiotic susceptibility testing) was positive for the presence of 100, 000 colonies of Escherichia coli ([E. coli.] a bacterium that lives in the digestive tracts of humans and animals) was in the patient's urine. The report further indicated the patient was treated with Macrobid (an antibiotic) 100 milligrams (mg) by mouth (P.O.) twice a day for seven days. Another report, dated August 6, 2014, indicated the presence of 25,000 colonies of Proteus mirabilis (bacterium found in soil, water, and the human intestinal tract) was in the patient's urine. The patient received treatment with Ciprofloxacin (an antibiotic) 500 mg P.O. twice a day for seven days. On October 6, 2014, the report indicated there were two organisms in Patient 6?s urine (100, 000 colonies of E. coli and 100, 000 colonies of Proteus mirabilis). Patient 6 was treated with Amikacin, an antibiotic, via IV infusion 500 mg once a day for seven days. On February 9, 2015, at 11:28 a.m., during an interview and a concurrent record review, LVN 1, the treatment nurse, reviewed Patient 6?s clinical record and was unable to find documentation the nurse assessed and documented Patient 6 having cloudy urine with sediment, prior to the evaluator identifying the abnormal urine characteristics during the initial tour. LVN 1 stated LVN 3 notified him of the sediment in the patient?s urine, after the tour, and he went and irrigated Patient 6's catheter as indicated in the physician?s PRN (whenever necessary) order.During an interview and concurrent record review, on February 9, 2015, at 1:48 p.m., the director of nursing (DON) was questioned about the medical indication for Patient 6?s indwelling catheter. The DON reviewed the patient's chart and stated the patient had a neurogenic bladder-urinary retention, but was unable to locate a long-term care plan to address the need for the urinary catheter and risks. The DON was asked if a urologist made the diagnosis and followed-up with the patient. The DON reviewed the chart and was unable to find any documentation of the verification of the patient?s diagnosis for neurogenic bladder. The DON stated an interdisciplinary team meeting would be conducted immediately to reassess the patient?s need of the indwelling catheter. A review of a physician?s telephone order, dated February 9, 2015, and timed at 2 p.m., indicated the physician was called and ordered a UA and C/S after the patient?s urine was observed cloudy with sediment and brought to the staff?s attention. The UA and C/S was positive for UTI and the patient was started on Macrobid 100 mg twice a day for seven days on February 12, 2015. On February 9, 2015, at 2:45 p.m., the assistant director or nursing (ADON), who was also the acting infection and prevention control nurse, was asked if Patient 6 had been identified in the facility's monthly surveillance data report for frequency of UTIs. He reviewed the infection control logs from June 2014 to February 2015. The ADON stated Patient 6 was listed in June 2014, August 2014 and October 2014 as having UTIs. When the ADON was asked, if the facility implemented methods to prevent further UTIs for Patient 6, the ADON stated, ?No.? He further stated there was no identification of the root cause for Patient 6's recurrent UTIs, or attempts to implement risk-reduction measures to reduce the occurrence of infections. As indicated the facility failed to assess the patient?s need of an indwelling urinary catheter and failed to initiate and implement a plan of care for the patient?s risk to develop UTI, until after the abnormal urine characteristics were brought to the staff?s attention on February 9, 2015. A review of the physician?s orders, dated February 10, 2015, and timed at 2:30 p.m., indicated to discontinue Patient 6's indwelling catheter, after the abnormal urine characteristics were brought to the staff?s attention and there were no medical indication for the patient?s continued use of the urinary catheter. In addition, the physician ordered for the patient to be referred to a urologist and an appointment was made for the patient to be seen by the urologist on March 2, 2015. On February 11, 2015 at 2:28 p.m., during an interview, LVN 4 stated Patient 6?s indwelling catheter had been discontinued for approximately 24 hours and the patient was urinating freely (without any retention of urine). LVN 4 stated after the removal, during the night shift, Patient 6 urinated 700 milliliters (mL) and continued to urinate freely the next day with no complaints. According to the nurses? notes reviewed from February 10, 2015 until February 17, 2015, the nurses documented the patient continued to urinate freely without any difficulty or urinary retention. During an interview, on February 11, 2015, at 2:31 p.m., Patient 6 stated, ?I feel much better without the catheter, because I can urinate on my own.?At 9:30 a.m., on February 12, 2015, during a telephone interview, the facility?s medical director stated that as much as possible they should try not use Foley catheters ([F/C]/indwelling urinary catheters), depending upon the indication of its use, they should monitor for UTIs, not just the lab, but clinically. The medical director stated they always discussed the issue of F/C usage. If the patient does not need it, it should be removed, because it puts the patient at risk for UTIs. A review of a facility?s policy revised on September 1, 2014, titled, ?Indwelling Catheter? indicated urinary catheters will be used only when medically indicated and the licensed nurse will assess the need for continued use of a catheter. The policy stipulated urinary retention was one of the clinical indicators, but only after it could not be treated or corrected medically or surgically and for which an alternative therapy was not feasible. The facility failed to: 1. Do an initial and continued assessment of Patient 6?s medical need of the indwelling urinary catheter. 2. Assess the characteristics of Patient 6?s urine, such as color, clarity, and odor for signs of infection. 3. Follow its catheter management interventions to prevent urinary tract infections (UTIs) for Patient 6. 4. Follow its policy related to indwelling catheter use, by not ensuring Patient 6?s urinary catheter was medically indicated. These violations either jointly separately or in combination presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 970000077 |
South Pasadena Care Center |
950011381 |
A |
10-Apr-15 |
DM3W11 |
11760 |
Title 22 72313 (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. The Department received a complaint on January 23, 2015, that the police was summoned to the facility on 4/15/14, at 0610 a.m., after a patient (Patient 23) was found not breathing. Upon the police arrival, the staff were initiating CPR ([Cardiopulmonary resuscitation], an emergency procedure performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in cardiac arrest) and thereafter the paramedics arrived and continued the resuscitation unsuccessfully. Patient 23 was pronounced dead at 0630, on 4/15/14. An unannounced complaint investigation was conducted during a licensing survey on 2/10/15.The facility?s staff failed by not: 1. Rechecking Patient 23?s blood sugar six hours after the administration of a STAT (immediate administration) order for insulin (medication used to treat high blood sugar), as stipulated in the physician?s order. 2. Notifying the physician on two separate occasion of the patient?s blood sugar reading above 250 milligrams per deciliter (mg/dL), as stipulated in the physician?s order. These failures, of the facility?s staff not following physician?s orders resulted in Patient 23?s blood sugars remaining elevated and had the potential to result in DKA (diabetic ketoacidosis) and lead to comatose (deep sleep, is a state of extreme unresponsiveness, in which an individual exhibits no voluntary movement or behavior) or death.An article by American Diabetes Association (ADA), titled, ?DKA (Ketoacidosis) & Ketones? indicated when cells do not get the glucose they need for energy, the body begins to burn fat for energy, which produces ketones. Ketones are chemicals the body creates when it breaks down fat to use energy when the body does not have enough insulin to use the glucose. When ketones build up in the blood it becomes more acidic, which is a warning sign the diabetes is out of control. According to the article, high blood glucose levels is one of the early warning signs that it is now a life threatening condition. A review of Patient 23?s Admission Face Sheet indicated the patient was a 77 year-old male, who was originally admitted from a general acute care hospital (GACH) to the skilled nursing facility (SNF) on 2/3/10, and last readmitted to the facility on 4/6/14, with diagnoses that included diabetes (high blood sugar).A review of a Minimum Data Set (MDS), an assessment and care screening tool, dated April 13, 2014, indicated the patient had the ability to understand and be understood. According to the MDS, Patient 23 was non-ambulatory and required extensive assistance from staff with activities of daily living. A review of the GACH?s history and physical, dated 4/2/2014, indicated the patient had a history of diabetes, peripheral vascular disease (a narrowing of blood vessels that restricts blood flow), cerebral vascular accident ([CVA/stroke] a disorder resulting from an impaired blood supply to parts of the brain) and Alzheimer?s disease (a type of dementia that causes problems with memory, thinking and behavior). The GACH?s discharge instructions, dated 4/6/14, indicated the patient was discharge to a SNF status-post a gastrostomy tube (GT) insertion (placement of a feeding tube through the skin into the stomach wall used for administration of liquid food, medications, and water).A review of a physician?s order, dated 4/6/14, indicated to perform an accucheck (blood sugar check) every other day before breakfast without insulin coverage (hormone produced by beta cells in the pancreas. It regulates the metabolism of carbohydrates and fats) and to call the physician if the blood sugar level was less than 60 or greater than 250 mg/dL. The order indicated to give eight ounces of orange juice via GT tube or Glucagon 1 mg (given to raise very low blood sugar) intramuscular if blood sugars were below 60 and recheck accucheck after 15-30 minutes. A review of a care plan, dated 4/6/14, titled, ?At risk for Hypoglycemia and Hyperglycemic related to diabetes mellitus? indicated the goal for the patient was for the blood sugar levels within the patient?s baseline daily for 90 days. The plan of care indicated the nurses would monitor for signs and symptoms (S/S) of hyperglycemia and hypoglycemia, such as excessive urination and thirst, nausea and vomiting, abdominal pains, weakness, sweating, headache, trembling, and irritability. However, there was no documented evidence the nursing staff were assessing the patient for any of these S/S. The nurses? plan of approaches included to initiate measures for both hypoglycemia and hyperglycemia immediately and notify the MD (physician) promptly.According to an article by the Mayo Clinic titled, ?Disease and Conditions of Diabetes,? a fasting blood glucose target range for an individual without diabetes is 70-100 mg/dL (3.9-5.6 mmol/L) and the American Diabetes Association recommends a fasting plasma glucose (sugar) level of 70?130 mg/dL for diabetes and after meals less than 180 mg/dL. (http://www.mayoclinic.org/diseases-conditions/diabetes/expert-blog/blood-glucose-target-range/BGP-20056575.)A review of Patient 23?s Medication Administration Record (MAR) for the month of April 2014, indicated on 4/13/14, at 6:30 a.m., the patient had an elevated blood sugar of 589 mg/dL. The physician was notified and ordered Novolog insulin 20 units subcutaneous ([SQ] an injection in which a needle is inserted just under the skin) to be administered one time. The physician also ordered to recheck the patient?s blood sugar six hours after the insulin was administered and to call him if the blood sugar was less than 60 mg/dL or greater than 250 mg/dL. In addition, the physician ordered to monitor the patient?s blood sugar twice a day for three days without a slide and scale coverage (without insulin coverage). However, a review of the nurse?s note, dated 4/13/14, and timed at 6:30 a.m., indicated the nurse administered the 20 units of insulin as prescribed by the physician for the elevated blood sugar of 589 mg/dlL., but there was no documentation Patient 23?s blood sugar was rechecked six hours after the insulin was administered at 6:30 a.m., as ordered by the physician. The patient?s blood sugar was not rechecked until ten hours later, at 4:30 p.m. At which time, the patient?s blood sugar remained elevated at 366 mg/dL, but there was no documentation the physician was notified of the results, as stipulated in the physician?s order and/or the nurses followed the patient?s plan of care to initiate measures for hyperglycemia and immediately and notify the MD (physician) promptly. On 4/14/14, at 6:30 a.m., Patient 23?s blood sugar was checked as ordered, and the blood sugar remained elevated at 514 mg/dL. The physician was notified and ordered 14 units of regular insulin to be given subcutaneously, as a one-time administration. Another accucheck was performed on 4/14/14, at 4:30 p.m., with an elevated blood sugar of 323 mg/dL., but there was no documented evidence the physician was notified of Patient 23?s elevated blood sugar.According to a nurse?s note, dated 4/15/14, and timed at 6:05 a.m., Patient 23 was found unresponsive without a blood pressure or respiration. The note indicated the patient?s advanced directive indicated the patient was a full code (all life-saving measures are taken in order to treat a patient after/during a respiratory or cardiac arrest) and CPR was initiated and 911 was called. The patient was pronounced deceased by the paramedics at 6:30 a.m. According to the death certificate, Patient 23 expired at the SNF on April 15, 2014, at 0630 a.m., with the immediate cause of death listed as arteriosclerotic heart disease (progressive narrowing and hardening of coronary arteries, due to atheroma deposition which, with time undergo calcification and ulceration).A review of an online article, by The Merck Manual, titled ?Atherosclerosis? indicated atherosclerosis is caused by repeated injury to the walls of the arteries. Many factors contribute to this injury, diabetes, being listed as one of them, due to the high blood sugar levels. According to the article, high levels of blood sugar can cause changes that lead to the hardening of the blood vessels (atherosclerosis). http://www.merckmanuals.com/home/heart_and_vessel_disorders/atherosclerosis/... On 2/10/15, at 3:15 p.m., during an interview and a concurrent record review, the director of nursing (DON), reviewed Patient 23?s clinical record and verified she was unable to find nurses? documentation for the following: 1. The patient?s blood sugar was rechecked as ordered on 4/13/14 at 12:30 p.m. 2. The notification of the physician, as ordered, of the patient?s blood sugar level being elevated at 366 mg/dL on 4/13/14, at 4:30 p.m. 3. The notification to the physician, as ordered, of the patient?s blood sugar level being elevated at 323 mg/dL on 4/14/14, at 4:30 p.m. On 4/2/15, at 12:45 p.m., during a concurrent record review and interview, the current director of nurses (DON) stated after reviewing Patient 23?s record, the physician?s order dated 4/13/14 had no order to call the physician if the BS was below 60 or above 250. The DON could not find any documentation the nurse called the physician on 4/13/14, at 5 p.m., of the patient?s BS being elevated at 366 and on 4/14/14 at 5 p.m. the BS being elevated at 323. The DON stated, ?As a nurse, I would have called the doctor for a blood sugar that high.? Patient 23?s care plan, dated 4/6/14, for risk of hypo/hyperglycemia, indicated the nurses would initiate measures call the physician promptly for low and high levels of blood sugars. On 4/3/15, at 10:55 a.m., during a telephone interview, the facility?s previous (just last month) medical director stated if the physician had an order for the patient?s blood sugar to be checked and notified if high or low, the nurse should have notified the physician. He stated the problem was the nurses did not know when to call the physician or not. He stated slide and scale insulin coverage is no longer approved by the Beer?s List (a guideline for healthcare professionals to help improve the safety of prescribing medications for older adults) so the physician needed to know if the elevated blood sugars were responding to the insulin. He stated he does not treat numbers, but patients and it?s pertinent for the nurses to have the capabilities to assess and report to the physicians. He stated if it was his patient he would have ordered an hemoglobin A1C (an important blood test that shows how well diabetes is being controlled), postprandial glucose test (a blood glucose test that determines the amount of a type of sugar, called glucose, in the blood after a meal) and if the blood sugar continued to be elevated he would have transferred the patient to the hospital, because the patient probably needed an insulin drip. The facility failed: 1. To recheck Patient 23?s blood sugar after six hours after administration of a STAT order of insulin, as stipulated in the physician?s order. 2. To notify the physician on two separate occasions of the patient?s blood sugar being above 250 milligrams per deciliter, as stipulated in the physician?s order. These violations either jointly separately or in combination presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 970000077 |
South Pasadena Care Center |
950011382 |
B |
10-Apr-15 |
Y0FK11 |
6589 |
Title 22 Section 72311 (a) (1) (C). (a) Nursing Services shall include, but not limited to, the following: Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating, and updating of the patient?s care plan as necessary by the nursing staff and other professionals involved in the care of the resident at least quarterly, and more often if there is a change in the patient?s condition.Based on observations, interviews and record review, the facility failed to update the plan of care and for Patient A, who was identified as being at risk for elopement, to address his removal and refusal to wear a wanderguard as ordered by the physician. This resulted in Patient A?s elopement from the facility unnoticed. On November 5, 2013, at 2:00 p.m., an unannounced visit was made to the facility to investigate an entity reported incident which indicated Patient A had eloped from the facility.A review of Patient A?s medical record indicated the patient was admitted to the facility, on August 12, 2013, with diagnoses which included psychosis (an abnormal condition of the mind, which involves the loss of reality) and schizophrenia (a mental disorder of abnormal social behavior, which includes false beliefs, confused thinking, auditory hallucinations, reduced social interaction, and inactivity).On August 12, 2013, the primary physician ordered a Wanderguard alarm bracelet to be applied on the patient related to wandering and also indicated to monitor the whereabouts of Patient A, while on the Wander guard alarm.A review of the care plan dated August 12, 2013, identified Patient A was at risk for elopement related to schizophrenia, psychosis, anxiety, and tends to wander around the facility. The patient care goals included keeping the patient safe and elopement risk will be managed daily for 90 days. The approaches indicated the patient would wear the Wanderguard/personal alarm and the staff were to monitor Patient A?s whereabouts while on the Wanderguard alarm, and to check at least every 2 hours and as needed (PRN).Review of the licensed nurse daily charting 7-3 shift contained no documented evidence of continued monitoring of Patient A?s whereabouts on 8/17/13, 8/21/13, 8/26/13, 8/29/13, 8/30/13, 9/4/13, 9/14/13, 9/15/13, 9/16/13, 9/21/13, 9/23/13, and 9/25/13. The licensed progress notes, dated November 1, 2013, at 7:30 a.m., indicated as the 7-3 shift nursing staff was conducting rounds, they observed that Patient A was missing from the facility. The staff searched the entire facility. At 7:30 a.m., the staff was instructed to search a three mile radius, but Patient A was not found. At 4:30 p.m., the police called and informed the facility that Patient A was located at a restaurant down the street from the facility. Staff went and brought Patient A, back to the facility. Nursing staff did a body check on the patient and found no injuries or abrasions, but it was noticed that Patient A?s Wander guard bracelet had been removed.On November 5, 2013, at 2:15 p.m., during an interview with Staff 1 regarding Patient A?s elopement, he stated that, on November 1, 2013, at around 7:00 a.m., at the change of shift, Patient A removed his Wanderguard bracelet and walked out of the facility. Staff 3 did her rounds and could not find Patient A, in his room. Staff 3 informed the other staff and they searched the entire facility and the neighborhood, but were not able to find the patient. At 7:30 a.m., the police were called, and they came out and took a report. At 4:30 p.m., the police located Patient A, who was brought back to the facility. Staff tried to apply a new Wanderguard bracelet but the patient resisted and refused to wear it.On November 5, 2013, at 2:30 p.m., in a further interview with Staff 1, he stated, Patient A had patterns of removing the Wander guard alarm (bracelet) since admission in August 2013. Staff 1 also stated, Staff 2 was aware of the patient?sbehavior. This behavior was also not identified in the IDT and the care plan was not updated. A review of the initial interdisciplinary team (IDT) conference dated August 22, 2013 (10 days after admission), attended by nursing, activities, dietary, and social services identified areas such as mobility, diagnosis, activity, weight/nutrition, overall resident condition, medications, and discharge planning, However, the IDT failed to identify Patient A?s risk of elopement related to schizophrenia and failed to identify monitoring of the resident while on Wander guard personal alarm in accordance with the plan of care developed on August 22, 2013. Additionally, there was no documentation regarding the resident?s removal and refusal to wear the Wanderguard since admission, as stated by Staff 1.On November 5, 2015, at 2:45 p.m., Patient A was observed in his room, lying in bed, with his back towards the door. An attempt was made to interview the patient, but he did not make any acknowledgement and refused to be interviewed. It was observed that Patient A was not wearing a Wanderguard bracelet on either his wrists or ankles. The facility?s wandering and elopement policy and procedure, dated December 2012, indicated that a licensed nurse, in collaboration with the Interdisciplinary Team (IDT), will assess residents upon admission, readmission, and quarterly and upon identification of significant change in condition to determine their risk of wandering/elopement. It also indicated that the patient?srisk for elopement and preventative interventions will be documented in the patient?s medical record, and will be reviewed and re-evaluated by the IDT upon admission, readmission, and quarterly and upon identification of significant change in condition.On November 6, 2013, at 3:15 p.m., an interview was conducted with Staff 2 regarding PatientA?s elopement. During this interview, it was mentioned that the elopement risk assessment form had not been updated, on November 1, 2013, after Patient A?s elopement. Staff 2 stated that Patient A would be sent to a secured facility which could properly care for the patient, as soon as possible. Patient A was sent out on December 3, 2013. The facility failed to update the plan of care for Patient A who was identified as being at risk for elopement, to address his removal and refusal to wear a Wanderguard as ordered by the physician. This resulted in the patient?s elopement from the facility unnoticed. This violation had a direct relationship to the health, safety and security of Patient A. |
| 970000077 |
South Pasadena Care Center |
950011396 |
A |
17-Apr-15 |
DM3W11 |
17650 |
?483.25(I) Unnecessary Drugs Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. The Department received an anonymous hand written letter via fax on August 20, 2014 indicating, ?Help us a resident (Resident 1) is smoking drugs in his room every day and the administrator was informed, but does nothing. Please help us, we are in danger.? An unannounced complaint investigation was conducted on August 21, 2014. The facility failed to ensure Resident 1's drug regimen was free from unnecessary drugs by: 1. Administering narcotics without adequate indication for its use. 2. Continuing to administer the prescribed narcotics when the resident was abusing illegal drugs and alcohol in the facility. 3. Continuing to administer narcotics and opiates in the potential adverse consequences, such as respiratory depression and the use of illegal drugs/alcohol. 4. Not implementing its zero tolerance policy for drugs and alcohol use in the facility. 5. Not adequately monitoring the resident for respiratory depression, as the medications administered were respiratory depressants and the resident had a diagnosis of chronic obstructive pulmonary disease (COPD). 6. Applying a Duragesic (Fentanyl) patch, potentially lethal drug, without any documented diagnoses for its use with a potential for drug interaction secondary to the resident consuming alcohol and other illegal drugs. These failures resulted in Resident 1?s drug regimen not being free of unnecessary drugs, in the presence of potential adverse consequences. Resident 1 smoked methamphetamine (a strong illegal CNS stimulant neurotoxic [poisonous effect on nerves and nerve cells]) in the bathroom after receiving Dalmane 30 milligram (mg) the night before (August 5, 2014) for sleep, and Ativan 4 mg throughout the day the day prior (August 5, 2014) and 1 mg of Ativan that morning (August 6, 2014), in addition to having a Fentanyl patch 75 mcg/Hr. reapplied on August 5, 2014 ([Duragesic] a potent, synthetic opioid analgesic narcotic pain medicine that may become habit-forming, misused or abused by placing it in the mouth or chewing, swallowing, injecting, or snorting which can lead to overdose. According to DailyMed, an official web-based provider of FDA medication labeling information, or package inserts, a Fentanyl patch is approximately 80 to 100 times more potent than morphine and roughly 15 to 20 times more potent than heroin.Resident 1 required a transfer to the general acute care hospital (GACH) by ambulance and once at the GACH was diagnosed with altered mental status (AMS) and received Narcan (a narcotic drug that reverses the effects (such as respiratory depression, sedation and low blood pressure) of other narcotics) 0.2 mg with bolus intravenous (IV) fluids with improvement in alertness. The resident?s blood pressure was low at 68/38 (normal reference range 120 80), with a heart rate of 60 (60-100 bpm normal reference range [bpm/beats per minute]) and a respiratory rate of 18 breathes per minute. According to the emergency room note, the facility gave a history of the resident being ?more out of it? receiving more Ativan than usual (4 mg the day prior). According to the GACH?s History and Physical (H/P), Resident 1 tested positive for methamphetamines in the urine while in the emergency room (ED). On August 21, 2014, at 3:37 p.m., during an observation of Resident 1?s room, there were seven small boxes of matches in a plastic storage drawer at the resident?s bedside. Resident 1 was asked if he usually stored the matches in his room he responded, ?Yes.? Resident 1 stated he recently returned from the GACH due to smoking methamphetamine in his bathroom. Resident 1 stated all he remembered from the incident was being able to get to his bed, when suddenly he began having breathing problems and had to be transferred via ambulance to the GACH to reverse the effects of the methamphetamine. A review of Resident 1's Admission Face Sheet indicated the resident was a 51 year-old male who was admitted to the facility on March 23, 2014 and re-admitted on May 29, 2014. The resident's diagnoses included chronic airway obstruction ([COPD] chronically poor airflow to the lungs), bilateral leg cellulitis (a bacterial infection involving the skin), depression (mood disorder) and coronary atherosclerosis heart disease (disease where there is narrowing or blockage of the coronary arteries [blood vessels that carry blood and oxygen to the heart]) with a cardiac pacemaker (medical device used to regulate the beating of the heart) and a history of tricuspid (valve of the heart) repair. According to a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated August 6, 2014, indicated the resident was able to make independent decisions regarding daily life tasks, but required supervision to limited assistance with his activities of daily living. According to the MDS, Resident 1 required supervision with ambulating. A review of an Interdisciplinary Team Conference (IDT) record, dated April 17, 2014, indicated a conference was held with Resident 1 and other staff members, which included Employee 6 in attendance (as indicated by his signature). The discussion was regarding the resident?s use of drugs and alcohol in the facility. The resident was informed about the facility?s policy and procedure regarding no drug and alcohol abuse in the facility and the goal was to provide a safe and drug-free environment. The IDT explained the effects of the drugs and alcohol with the current medications the resident was taking. A review of the facility?s policy, revised on October 11, 2011, titled, ?Resident Drug & Alcohol Abuse,? indicated the purpose of the policy was to provide a safe and drug-free environment for residents while in the facility. The policy stipulated the facility had a zero tolerance for the abuse of drugs and alcohol in the facility or on the grounds and any resident found in violation will be discharged to a more appropriate setting for care. The policy, under Section VIII., Violation, C, indicated upon violation the resident will also be subjected to drug screening to test for the presence of any illegal substances. Another IDT Conference Record, dated May 2, 2014, indicated the resident was counseled again after a non-facility?s insulin syringe was found in the resident?s room. The note indicated the resident was informed of the zero tolerance for drugs and alcohol in the facility and his non-compliance will result in an appropriate discharge. A review of a History and Physical (H/P) of Resident 1?s clinic visit with the cardiologist (a doctor with special training and skill in finding, treating and preventing diseases of the heart and blood vessels), dated August 6, 2014 and timed at 11:26 a.m., indicated the resident informed the physician he was having pain and swelling of the legs and he was not being taken care of where he lives (in the facility) and he had not slept in days. However, according to the cardiologist?s assessment the edema of Resident 1?s lower extremities was unchanged with the severity level being moderate. The resident?s heart rate was recorded at 78 beats per minute and blood pressure was recorded at 110/68 (sitting). A review of a social worker (SW) note, dated August 6, 2014, without a time, indicated the SW went into Resident 1?s room (upon his return from cardiologist appointment) and was attempting to interview the resident, but the resident was mumbling and attempting to open his eyes, but could not. According to the SW's note, it was her impression the resident was under the influence of something and reported the situation to the director of nursing and administrator to take action. Contrary to the SW?s findings and documentation of the resident?s unresponsiveness and her impression of him being under the influence of ?something,? and the resident?s statement he smoked methamphetamine, had problems breathing, and had to be transferred to the GACH for reversal of the amphetamines. A nurse?s note, dated August 6, 2014, and timed at 3 p.m., indicated the resident was to be transferred to the GACH for leg swelling and pain. According to the nurse?s note Resident 1 left the facility at 4:30 p.m. via ambulance. According to the GACH?s history and physical for Resident 1, the resident arrived to the emergency room with altered mental status ([AMS] any state of awareness that differs from the normal awareness of a conscious person). A review of the GACH records, dated August 6, 2014, indicated Resident 1 was admitted to the GACH for AMS secondary to the chronic opiate use (narcotic pain killer that directly depresses the central nervous system) and the use of methamphetamines. The resident required an emergency treatment of IV Narcan and bolus IV fluids to improve the AMS.A review of the resident's re-admission nursing note, dated August 9, 2014, and timed at 7 p.m., indicated the resident?s primary physician (Physician 2) was notified of the resident?s status of being positive for methamphetamine.The physician?s recapitulation order indicated Resident 1?s drug regimen included the following medications: 1) Norco ([acetaminophen 325 mg and hydrocodone 10 mg) for moderate to severe pain one tablet to be given orally every 4 hours PRN (whenever necessary) for severe pain,2) Ativan (a benzodiazepine used to treat anxiety disorders or anxiety associated with depression) 1 mg orally every 4 hours PRN anxiety was initially ordered and changed on August 12, 2014 to be given 1 mg by mouth three times a day (TID),3) Soma (used to treat muscle spasm) 350 mg one tablet by mouth TID PRN ordered on August 11, 2014, 4) Benadryl 50 mg two caps every night for allergic rhinitis, ordered on August 25, 2014; 5) Dalmane (a hypnotic agent used to treat insomnia) 30 mg orally every night PRN was ordered on May 29, 2014, and changed to Restoril 30 mg (used to treat insomnia symptoms) every night on August 19, 2014 (after the pharmacist consultant informed the facility that Dalmane was a high risk drug and should be decreased). 6) In addition to a Fentanyl 75 mcg/HR patch being applied topically every 72 hours for pain management. According to DailyMed, Fentanyl had a ?black box? warning related to the potential adverse effect of respiratory depression and death, indicating that, respiratory depression and death may occur with use of fentanyl transdermal system, even when fentanyl transdermal system has been used as recommended and not misused or abused. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9baf2912-9d0f-412a-8fbf-617f6a4f91edAccording to DailyMed (under Warnings and Precautions), Fentanyl had potent interactions with other CNS depressants, the concomitant use of fentanyl transdermal system with other central nervous system depressants, including, but not limited to, other opioids, sedatives, hypnotics, tranquilizers (e.g., benzodiazepines), general anesthetics, phenothiazines, skeletal muscle relaxants, and alcohol, may cause respiratory depression, hypotension, and profound sedation or coma. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9baf2912-9d0f-412a-8fbf-617f6a4f91ed However, there was no physician?s order or documented evidence in Resident 1?s clinical record that the nursing staff was monitoring the residents? respiratory condition (COPD) with the use of the Ativan, Norco, and Fentanyl patch. A review of the August 2014?s Medication Administration Record (MAR), indicated the Fentanyl (opioid agent) 75 micrograms patch was applied on August 5, 2014, at 9 a.m. as per the physician?s order every 72 hours. Resident 1 received 4 mg of Ativan on August 5, 2014 and Dalmane 30 mg at 10 p.m. On August 6, 2014, at 10:30 a.m., Resident 1 received 1 mg. of Ativan prior to smoking methamphetamine.According to the Controlled Drug Records, Resident 1 received the following: Norco 10-325 mg 25 tablets in May 2014 112 tablets in June 2014 70 tablets in July 201462 tablets in August 2014Dalmane 30 mg 5 capsules in May 2014 23 capsules in June 2014 25 capsules in July 2014 13 capsules in August 2014 (August 1-18, 2014) Restoril 30mg 13 capsules from August 19-31, 2014 1 capsule in September 2014 (discontinued 9/2/14) Soma 350 mg 24 tablets from August 11-31, 2014 39 tablets September 2014 Benadryl 50mg 6 capsules from August 25-31, 2014 29 capsules September 2014 Ativan 1 mg 28 tablets in May 2014 92 tablets in June 2014 63 tablets in July 2014 67 tablets in August 2014 In addition to the application of a Fentanyl 75 mcg/HR patch every 72 hours. According to Daily Meds, an online site, Ativan may lead to physical and psychological dependence and the risk increases with the higher doses and longer term used. In general it should be prescribed for short periods, e.g. two-four weeks. It also indicated it should not be used in residents with depression and COPD, as in Resident 1?s case, due to the risk of suicide and further compromising the resident?s respiratory functions. The literature stipulated elderly or debilitated residents may be susceptible to the sedative effects and should be monitored frequently and the initial dosage should not exceed 2 mg. http://dailymed.nlm.nih.gov/dailymed/search.cfm?labeltype=all&query=ativan On April 2, 2015 at 1:40 p.m., during an interview and declaration obtained, Employee 6 stated Resident 1 was definitely using drugs in the facility. Employee 6 stated Resident 1?s behavior was very erratic, hostile and threatening toward staff and peers. The resident would sleep all day and up at nights. Employee 6 stated the charge nurses were afraid and would call him because the resident would smoke cigarettes in his room. He stated they would ask the resident to look in his room, because they suspected drug use, but he was quite masterful and they would not find anything.During a telephone interview, conducted on April 3, 2015, at 10:55 a.m., the facility?s previous medical director stated Fentanyl patches should be used for residents who have a terminal illness, such as cancer, especially metastasis (the spread of a cancer or disease from one organ or part to another not directly connected with it) to the bone. He stated the Fentanyl patch by itself can be lethal, not to mention in the combination with Norco and Ativan and the illegal drugs the resident was using. When he was asked how he would treat a resident such as Resident 1. He stated he would first send the resident to be evaluated by a pain management physician to justify the need for the Fentanyl patch and the other drugs and /or send the resident to the hospital if the pain physician was not available. The medical director stated the facility had a large amount of drug abusing residents and they were quite manipulative and pushy about getting their drugs. On April 8, 2015, at 10:25 a.m., during a telephone interview, Resident 1?s primary physician (Physician 2) stated she was not aware the resident was smoking and using drugs in his room. She stated the nurses should inform the physician if a resident was using drugs or alcohol in the facility or when they go out on pass and use drugs or alcohol so they can refer the resident to their psychiatrist to send the resident for detox. She stated she was never informed about Resident 1 using drugs or smoking cigarettes in his room. She stated had she known they would have sent the resident out for detox. She stated, ?We don?t let our residents stay if they are using illegal drugs.? However according to a nurse?s note, dated August 9, 2014, and timed at 7 p.m., Physician 2 was notified of the resident?s return and being positive for amphetamines at the GACH. The facility failed by: 1. Administering narcotics without adequate indication for its use. 2. Continuing to administer the prescribed narcotics when the resident was abusing illegal drugs and alcohol in the facility. 3. Continuing to administer narcotics/opiates in the potential of adverse consequences, such as respiratory depression and the use of illegal drugs/alcohol. 4. Not implementing its zero tolerance policy for drugs and alcohol use in the facility. 5. Not adequately monitoring the resident for respiratory depression, as the medications administered were respiratory depressants and the resident had a diagnosis of chronic obstructive pulmonary disease (COPD). 6. Applying a Duragesic patch, potentially lethal drug, without any documented diagnoses for its use with a potential for drug interaction secondary to the resident consuming alcohol and other illegal drugs. 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. |
| 970000077 |
South Pasadena Care Center |
950011399 |
A |
17-Apr-15 |
MO4S11 |
8791 |
483.25 (h) Accidents The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The Department received an anonymous hand written letter via fax on August 20, 2014 indicating, ?Help us a resident (Resident 1) is smoking drugs in his room every day and the administrator was informed, but does nothing. Please help us, we are in danger.? An unannounced complaint investigation was conducted on August 21, 2014. The facility failed to adequately supervise Resident 1 to prevent accidents by not: 1. Implementing the resident?s plan of care that stipulated the resident required supervision while smoking. 2. Following its policy regarding incendiary devices (causing or designed to cause fires) would only be stored by the facility?s staff. 3. Educating the resident regarding smoking and oxygen usage. 4. Ensuring the resident followed the Smoking Contract he signed. The facility?s failures and Resident 1?s non-compliance to adhere to the facility?s policy had the potential to result in serious physical harm to Residents 1 and 2, other residents, and staff in the facility due to the hazardous environment of the use of oxygen and Resident 1 smoking in the room. On August 21, 2014, at 3:37 p.m., during an observation of Resident 1?s room, there were seven small boxes of matches in a plastic storage drawer at the resident?s bedside. Next to the plastic drawers was an oxygen concentrator with nasal cannula tubing connected. However, there was not a ?No Smoking? sign on the outer door, as stipulated in the policy for general procedure for administration of oxygen. Resident 1 was asked if he usually stored the matches in his room he responded, ?Yes.? Resident 1 stated he had just returned from the general acute care hospital (GACH) related to smoking methamphetamine (a strong CNS stimulant neurotoxic [poisonous effect on nerves and nerve cells], addictive, causes brain damage, the mode includes smoking, ingesting or inhaling it) in his bathroom. Resident 1 stated all he remembered from the incident was being able to get to his bed, when suddenly he began having breathing problems and had to be transferred via ambulance to the general acute care hospital (GACH) for evaluation and treatment to reverse the effects of the methamphetamine. A review an article by NFPA (National Fire Protection Association) revised in November 2008, titled, ?Fire Safety Tips for Home Medical Oxygen Users,? indicated smoking should not be allowed where oxygen is present and/or in use. The article indicated oxygen does not have to be in use to be a hazard, because the oxygen may have saturated the air, clothing, curtains, furniture, bedding, hair or anything in the area to make it easier for a fire to start and spread. According to the article, a no smoking sign should be posted outside to remind residents not to smoke in the area. A review of the GACH?s records indicated the resident was admitted for altered mental status (any state of awareness that differs from the normal awareness of a conscious person) secondary to the chronic opiate (narcotic pain killer that directly depresses the central nervous system) use and the abuse of methamphetamines.At 3:49 p.m., on August 21, 2014, during an interview with Resident 1, the administrator was passing by the resident's room and was asked to verify that the resident had seven full small boxes of matches and one lighter his drawer. The administrator immediately removed the matches from the resident's room and informed the resident of the facility's smoking policy. According to the administrator, residents are not to have matches or lighters in their rooms. A review of Resident 1's Admission Face Sheet indicated the resident was a 51 year-old male who was admitted to the facility on March 23, 2014 and recently readmitted on August 9, 2014. The resident's diagnoses included, but not limited to chronic airway obstruction ([COPD] chronically poor airflow to the lungs), depression (mood disorder) and coronary Atherosclerosis heart disease (disease in which there is a narrowing or blockage of the coronary arteries (blood vessels that carry blood and oxygen to the heart) with a cardiac pacemaker (medical device used to regulate the beating of the heart) and history of tricuspid (valve of the heart) repair.According to a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated August 6, 2014, the resident was able to make independent decisions regarding daily life tasks, but required supervision to limited assistance with his activities of daily living. According to the MDS, Resident 1 required supervision with ambulating. A review of a recapitulation of the physician?s order, dated May 29, 2014, indicated for the resident to receive oxygen 2 liter per minute via nasal cannula PRN (whenever necessary) for shortness of breath and COPD and to titrate oxygen for an saturation< 92% (95 percent level or above within normal limits, Levels between 80 percent and 94 percent are considered low but anything lower is a sign of hypoxemia). The physician?s order also indicated to monitor the oxygen saturation every shift. A review of a Smoking Contract, dated August 5, 2014, indicated the resident understood smoking was only allowed in the outdoor designated smoking area of the facility and lighting materials were to be stored by the facility?s staff per the facility?s policy, as per his signature. A care plan titled, ?Smoker,? dated May 29, 2014, indicated the resident required supervision while smoking and may smoke only in designated areas and should have no access to matches and lighters, as stipulated in the facility?s policy. The care plan also indicated the resident may not smoke when oxygen was in use or smoke near flammable substances. However, the plan of care did not specify a method of supervision and if the resident was educated regarding the use of oxygen and smoking to ensure the plan of care was implemented to meet the goal. The goal indicated the resident would be able to smoke according to the facility?s policy with precautions taken for the resident?s safety, as well as the safety of others, with the resident not having any smoke related incidents in the facility within 90 days. A review of Resident 2?s records (Resident 1?s roommate) indicated the resident was a 51 year-old male, who was initially admitted to the facility on September 28, 2012 and re-admitted on July 23, 2014. His diagnosis included chronic airway obstruction disease (COPD) and received singular (a medication prescribed to treat asthma) 10 mg by mouth every evening and DuoNeb (a combination of two medicines that work together to help open the airways in the lungs. It is used to help treat airway narrowing (bronchospasm) that happens with chronic obstructive pulmonary disease [COPD])3 ml 1 UD via an HHN (hand held nebulizer [drug delivery device used to administer medication in the form of a mist inhaled into the lungs]) twice a day for COPD and asthma. Resident 1 smoking in the room put Resident 2 at risk for an asthma attack and/or bronchospasm. On April 2, 2015 at 1:40 p.m., during an interview and declaration obtained, Employee 6 stated Resident 1 was definitely using drugs in the facility. Employee 6 stated Resident 1?s behavior was very erratic, hostile and threatening toward staff and peers. The resident would sleep all day and up at nights. Employee 6 stated the charge nurses were afraid and would call him because the resident would smoke cigarettes in his room. He stated they would ask the resident to look in his room, because they suspected drug use, but he was quite masterful and they would not find anything.A review of the facility?s policy and procedure titled, "Smoking by Residents," revised on May 1, 2014, indicated the purpose was to provide a safe environment for the residents, staff and visitors and smoking was only allowed outside in the designated marked smoking areas. The policy indicated oxygen use was prohibited in the smoking areas and incendiary devices will be stored by the facility?s staff.The facility failed by not: 1. Implementing the resident?s plan of care that stipulated the resident required supervision while smoking. 2. Following its policy regarding incendiary devices would only be stored by the facility?s staff. 3. Educating the resident regarding smoking and oxygen usage. 4. Ensuring the resident followed the Smoking Contract he signed. 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. |
| 970000077 |
South Pasadena Care Center |
950011405 |
A |
17-Apr-15 |
DM3W11 |
6117 |
Title 22 Division 5 Chapter 3 Article 3- 72301 (f) The facility shall ensure that all orders, written by a person lawfully authorized to prescribe, shall be carried out unless contraindicated. Title 22 Division 5 Chapter 3 Article 3- 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 facility failed to immediately provide cardiopulmonary resuscitation (CPR/ lifesaving technique useful in many emergencies) as ordered by the physician in accordance to CPR guidelines and the facility?s policy and procedure.On 2/12/15, an unannounced complaint visit was conducted at the facility. Patient 24?s admission facesheet indicated, he was an 87 year old male, who was originally admitted to the facility on 3/23/11, with diagnoses that included chest pain, muscle weakness and atrial fibrillation (heart rhythm characterized by rapid and irregular beating).The patient's plan of care dated 11/20/12, indicated Patient 24 required total to extensive assistance activities of daily living. The comprehensive assessment dated 12/28/13, indicated Patient 24 had the ability to express ideas and wants, understood others, and passed the brief mental status interview. It further noted the resident required total to extensive assistance with his activities of daily living. The physician orders for life-sustaining treatment(POLST) dated 3/26/11, indicated to provide CPR when the patient is found with no pulse and is not breathing. Cardiac arrest is characterized by the absence of a pulse and breathing in an unconscious victim. The current approach for handling a cardiac arrest is to provide CPR utilizing the chest compressions-airway-breathing (CAB) sequence. The first step when performing CPR, is to perform a carotid pulse check for at least 5 but no more than 10 seconds. If a pulse is felt, give one rescue breath every 5 to 6 seconds and recheck every 2 minutes. If no pulse is felt, initiate compression-airway-breathing (CAB) Medical-Surgical Nursing Ninth edition, Appendix A Basic Life Support for Health Care Providers, page 1696, Cardiopulmonary Resuscitation (CPR)). The licensed nurses progress notes dated 4/23/14, at 3:45 p.m., indicated certified nursing assistant (CNA 3) saw Patient 24 lying in bed, awake, alert and verbally responsive at 3:30 p.m., At 3:45 p.m., 15 minutes later, CNA 3 approached licensed vocational nurse (LVN 5) and registered nurse (RN 2) to notify them the patient was unresponsive (not responding to stimulation) with vomit on the right shoulder. Further review of the licensed nurse notes indicated the resident was assessed by LVN 5 and RN 2 and had no pulse and was not breathing. LVN 5 and RN 2 attempted to assess the resident?s oxygen saturation level and blood pressure but could not obtain an oxygen saturation level or blood pressure reading.CNA 3 failed to follow the first step of CPR, which is to check Patient 24?s pulse, instead CNA 3 "approached" LVN 5 and RN2 to notify them the patient was unresponsive. CNA3, LVN 5 and RN2 did not follow the established guidelines for CPR. A review of personnel records for CNA 3, LVN 5 and RN 2 indicated that they were CPR certified.Patient 1?s medical record revealed no documentation that LVN 5 and RN 2 conducted an assessment to determine unresponsiveness according to Medical-Surgical Nursing Ninth edition, Appendix A Basic Life Support.A subsequent progress note timed 3:48 p.m., indicated, 911 (emergency response) was called and CPR was initiated by the facility staff. The progress notes further indicated at 3:50 p.m., the paramedics arrived at the facility and took over CPR. A subsequent note indicated, the patient was pronounced dead by the paramedics at 4:12 p.m.CPR can be lifesaving, but it is best performed by those who have been trained in an accredited CPR course. Time is very important when an unconscious person is not breathing. Permanent brain damage begins after only 4 minutes without oxygen, and death can occur as soon as 4 - 6 minutes later. When someone starts CPR before emergency support arrives, the patient has a much greater chance of surviving. Yet, when most emergency workers arrive at a cardiac arrest, they usually find no one giving CPR. Timing is very important when an unconscious person is not breathing. Permanent brain damage begins after only four (4) minutes without oxygen, and death can occur as soon as 4-6 minutes later. http://www.nlm.nih.gov/medlineplus/ency/article/000013.htm.During an interview with the assistant director of nursing (ADON), on 2/13/15 at 10:15 a.m., when asked when CPR was initiated for Patient 24, he reviewed the documentation and stated it was started three minutes after the resident was found unresponsive. When further asked when CPR should be initiated based on the facility practice and nursing practice, he stated immediately when the patient is found unresponsive. The policy and procedure titled "Cardiopulmonary Resuscitation" dated 1/1/12, indicated individuals certified in basic CPR should perform the resuscitation efforts immediately on the patients. The policy delineates for a one person rescue, the staff is to call for help and send someone to contact the emergency medical services (EMS) or call a code. Followed by the opening of the patient's airway, check breathing, assess circulation and begin compressions or CPR. Attempts to interview LVN 5 and RN 2 were unsuccessful.The facility failed to immediately provide cardiopulmonary resuscitation (CPR/ lifesaving technique useful in many emergencies) as ordered by the physician in accordance to CPR guidelines and the facility?s policy and procedure.The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 950000003 |
SAN GABRIEL CONVALESCENT CENTER |
950013272 |
B |
9-Jun-17 |
S1QZ11 |
9191 |
F225 - Abuse
? 483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
On 3/31/2017 at 11:40 a.m., an unannounced visit was made to the facility to investigate a complaint regarding an injury of unknown source.
Based on observation, interview and record review, the facility failed to immediately report (within 24 hours) Resident 1?s injury of unknown source to the State survey and certification agency.
A review of the admission face sheet indicated Resident 1 was admitted to the facility on XXXXXXX 15 with diagnoses that included diabetes mellitus (high blood sugar levels over a prolonged period resulting to frequent urination, increased thirst, and increased hunger), dementia (long term and gradual decrease in the ability to think and remember affecting a person's daily functioning), hypertension (long term medical condition in which blood pressure is high) and atrial fibrillation (an abnormal heart rhythm characterized by rapid and irregular beating).
A review of document titled "History and Physical Examination" dated 7/26/16 indicated Resident 1 did not have the capacity to understand and make decisions.
A review of Minimum Data Set (MDS), a comprehensive assessment tool, dated 1/17/17 indicated that Resident 1 had a brief interview for mental status (BIMS - screens for cognitive impairment) score of 2 (a score of 0-7 indicates severe cognitive impairment), required limited assistance with one person physical assist for transfer, walk in room, toilet use, required extensive assistance with one person physical assist for personal hygiene and bathing.
A review of Resident 1's "License Nurse Record" dated 3/7/17 indicated Resident 1 refused RNA ambulation and her left leg felt weak when ambulating.
During a concurrent observation and interview of Resident 1 on 3/31/17 at 1:15 p.m., Resident 1 was observed sitting up on a wheelchair at her bedside. Resident 1 stated that she did not have any fall incidents and no injuries.
During an interview with the Director of Staff Development (DSD) on 3/31/17 at 1:18 p.m., DSD stated that Resident 1 is confused with poor memory.
During an interview with Certified Nursing Assistant (CNA 1) on 3/31/17 at 1:20 p.m., CNA 1 stated that she showered Resident 1 in the morning of 3/9/17. CNA 1 stated Resident 1 did not fall in the shower and had no complaints of pain after the shower.
During an interview with the Licensed Vocational Nurse (LVN 1) on 3/31/17 at 1:30 p.m., LVN 1 stated he was informed by the family of Resident 1 that Resident 1 had claimed that she fell prior to going out on pass on 3/9/17. LVN 1 stated Resident 1 and the family member still went out on pass on 3/9/17 around lunch time. After they returned LVN 1 interviewed and assessed Resident 1. Resident 1 told him that she did not fall. LVN 1 stated he assessed Resident 1 and found no pain and no swelling to Resident 1's left hip. LVN 1 further stated that he reported the incident to the attending physician, who ordered an x-ray (photo image of a body part to check for internal structures including bone).
A review of Resident 1's "Physician Telephone Orders" dated 3/9/17 indicated an order of X-Ray of left hip, thigh, knee, lower leg and foot.
A review of document titled, "Imaging Report of left hip with pelvis" dated 3/9/17 indicated an acute, displaced femoral neck fracture (broken thigh bone near the hip joint), addendum included mineralization appears age appropriate, for osteopenia/osteoporosis determination, recommend a DEXA (Dual-energy X-ray absorptiometry) scan {a means of measuring the amount of mineral in bone and is used to diagnose osteopenia (a condition in which bone mineral density is lower than normal) and osteoporosis(disease where increased bone weakness increases the risk of a broken bone}.
A review of Resident 1's "Physician Telephone Orders" dated 3/10/17 indicated an order to transfer Resident 1 to General Acute Care Hospital for femoral neck fracture.
During an interview with the Director of Nursing (DON) on 3/31/17 at 1:46 p.m., the DON stated that she interviewed Resident 1, who told her that she did not fall. The DON stated that Resident 1 claimed that her legs were weak a couple of days prior to 3/9/17. The DON stated nobody knew how the fracture happened and the attending physician said that the fracture could have occurred during ambulation combined with co-morbidities (presence of one or more diseases or disorders) including osteopenia/osteoporosis. The DON stated that DEXA scan was not done to Resident 1 to confirm the diagnosis of osteopenia/osteoporosis.
During an interview with the Administrator on 3/31/17 at 2:00 p.m., Administrator stated that the department managers of the facility made a determination that Resident 1's injury was not a reportable incident. Administrator also stated that nobody knows how Resident 1 sustained the fracture. Administrator also stated that the facility's determination that led to Resident 1's fracture was due to Resident 1's co-morbidities. Administrator further stated that Resident 1's fracture was not an injury of unknown source.
During an interview with Resident 1's daughter on 5/18/17 at 8:51 a.m., Resident 1's daughter stated that she was not aware if Resident 1 had a fall incident. Resident 1's daughter also stated that Resident 1 is confused and could not tell her how Resident 1 got the fracture.
A review of General Acute Care Hospital (GACH) notes titled, "History and Physical", dated 3/13/17 indicated left hip fracture as the reason for admission and plan for orthopedic consult.
A review of GACH notes titled, "Operative Report" dated 3/11/17 indicated Resident 1 underwent left hip hemiarthroplasty (a surgical procedure in which the femoral head of the hip joint is replaced by a prosthetic implant). The Operative Report did not indicate that evidence of osteoporosis was found during Resident 1's hip replacement operation.
A review of GACH notes titled, "Discharge Summary Report" dated 3/16/17 indicated Resident 1 was discharged back to skilled nursing facility on XXXXXXX17. Resident 1's discharge diagnoses included: Status post left hip fracture with need for hip replacement, urinary tract infection, and diabetes. No diagnoses of osteopenia/osteoporosis were indicated.
A review of an undated facility policy and procedure titled, "Patient Abuse and Mistreatment", indicated:
IV. Identification - Facility shall institute procedure of identifying unusual occurrences and events, such as suspicious bruising of residents, unexplained skin tears, fractures, etc. (etcetera), that may constitute abuse. Such procedural guidelines shall also provide for directions of necessary investigative efforts.
a. Facility administrator and/or designee shall ensure the prevention, monitoring and identification of unusual occurrences and events that may constitute abuse.
b. Any incidences or occurrences that may constitute abuse shall be recorded on the Incident Report Form and reported to Director of Nurses, facility Administrator and facility Abuse Coordinator (if different from the facility administrator) immediately after and/or no later than 24 hours after the identification of the unusual occurrences or events constituting abuse or probable abuse. (Please note that facilities are required to report to the Department of Health Services any incident of unknown origin. It is therefore, very vital to take extra caution in documenting that the incident is of unknown origin, unless proven otherwise).
A review of an undated facility policy and procedure titled, "Abuse Allegation Reporting", indicated:
Policy: All allegations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident's property will be reported immediately to the Administrator/Abuse Coordinator.
Procedure:
1. All allegations involving abuse of any type will be reported by the Charge Nurse and/or supervisor immediately to the Director of Nursing.
2. Please note that as a mandated reporter, an employee who identifies suspected abuse committed against an individual who is a resident must also report the incident to one local law enforcement entity by phone within 24 hours and provide a written report to the local ombudsman, L & C (licensing and certification) program and local law enforcement within 24 hours for non-serious bodily injury. For serious bodily injury, the requirement requires a phone report within 2 hours to local law enforcement, Ombudsman and the L & C program.
Therefore, the facility failed to immediately report (within 24 hours), Resident 1?s injury of unknown source to the State survey and certification agency.
This violation had a direct relationship to the health, safety, or security of the resident. |
| 950000085 |
SANTA ANITA CONVALESCENT HOSPITAL |
950013322 |
B |
30-Jun-17 |
QVCT11 |
8203 |
483.12(a) (1) FREE FROM ABUSE/INVOLUNTARY SECLUSION
483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident?s symptoms.
483.12(a) The facility must
(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
On January 27, 2017, at 10:55 a.m., an unannounced visit was made to the facility to investigate an entity reported allegation that Certified Nursing Assistant (CNA) 1 verbally abused Resident 1.
Based on interview and record review, the facility failed to ensure Resident 1 was free from verbal abuse by Certified Nursing Assistant (CNA) 1. This resulted in mental and emotional harm to Resident 1 by making the resident cry when reminded of the incident and feel scared of CNA 1.
A review of the Record of Admission of Resident 1 indicated the resident was originally admitted to the facility on XXXXXXX, 2016, and was readmitted on December 23, 2016 with diagnoses of cellulitis (common infection of the skin and the soft tissues underneath) of abdominal wall, abnormal posture, chronic pain syndrome, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and major depressive disorder.
The Minimum Data Set (MDS), a standardized assessment and care planning tool, dated December 4, 2016, indicated Resident 1 understood others and was able to make self understood, scored a 15 on the brief interview for mental status (BIMS, a score of 13 to 15 means cognitively intact), memory was intact, did not display any physical, verbal, or any other behavioral symptoms directed at others or to self, and required extensive assistance to total dependence with assistance of two or more staff with bed mobility, transfer, dressing, and bathing.
A review of the facility's investigative report dated January 12, 2017, indicated on January 12, 2017, at 11 a.m., CNA 2 who was giving Resident 1 a shower notified Licensed Vocational Nurse (LVN) 1 that Resident 1 was crying. LVN 1 immediately went to Resident 1 and asked why she was crying. Resident 1 then reported to LVN 1 that about a month ago, CNA 1 called her a cry baby and that she cries at everything. Resident 1 also reported that when CNA 1 used the mechanical lift (a device designed primarily to lift and transfer patients to/from the bed, chair, toilet, and floor) on her, it caused pain to her toes by pinching them. LVN 1 immediately assessed the resident's toes and did not see any redness, swelling or injuries. The report further indicated, the facility made multiple attempts to contact CNA 1, but was unable to interview her due to her being on medical leave.
Further review of the facility's investigative report dated January 12, 2017, indicated during an interview with Resident 1 on January 12, 2017, at 4 p.m., when asked why she did not report the incident right away, Resident 1 stated that it happened about a month ago and she did not report it because according to her, "I am just like that." Resident 1 stated that she was reminded of the incident when she had her shower today, cried and became emotional.
According to a nurse's note dated January 12, 2017, at 11 a.m., Resident 1 complained about her toes being pinched during shower with CNA 1. CNA 1 called her a cry baby and crying for everything, which make her, feel very sad. The note indicated Resident 1 wanted CNA 1 removed from taking care of her. The note further indicated Resident 1's responsible party (son) was notified.
A review of a nurse's note dated January 13, 2017, at 1 p.m., indicated Resident 1's son visited the resident last night. The note indicated the son confirmed with his mom what had happened and explained that his mom would not make up any stories.
A review of the facility's untimed interview with CNA 1 dated January 20, 2017, indicated CNA 1 denied calling the resident a cry baby. CNA 1 stated she was aware that Resident 1 accidentally hit the mechanical lift, but she did not report it to the charge nurse. CNA 1 also stated that she recalled Resident 1 crying and saying it hurt, and that she told Resident 1 "You cry at everything and that she cries at everything too."
During an interview on January 27, 2017, at 11:26 a.m., LVN 1 stated that Resident 1 complained to her that CNA 1 assisted her with the mechanical lift and the lift made her feel like she was being pinched on her toes. Resident 1 complained that CNA 1 did not bother to see what was wrong. CNA 1 told Resident 1 that she was a cry baby and she cries about everything. LVN 1 stated that Resident 1 did not know the exact date of the incident and this is the first time Resident 1 complained about CNA 1. According to LVN 1, Resident 1 is alert and oriented, knows what is going on and has no history of making up stories.
During an interview on January 27, 2017, at 12:10 p.m., Resident 1 stated that over a month ago, CNA 1 was putting her back to bed using the mechanical lift when her knee and toe got caught in it somehow and made her feel "so much pain." Resident 1 stated that she was crying and screaming because it hurt, but CNA 1 did not stop and continued to put her back to bed. According to Resident 1, when she got in the bed, CNA 1 told her she was such a cry baby and cries about everything. Resident 1 stated that she did not like how CNA 1 talked to her. That made her feel scared of CNA 1 and scared of using the lift again. Resident 1 further stated that she did not tell anyone what happened for a long time because she is the type of person who keeps everything inside.
During an interview on January 27, 2017, at 1:15 p.m., the Director of Nursing (DON) stated that CNA 1 was still on medical leave and was suspended with possible termination when she reports back to the facility.
During a telephone interview on January 31, 2017, at 8:14 a.m., CNA 1 stated that over a month ago, something might have happened when she was putting Resident 1 back to bed with the mechanical lift. CNA 1 stated that she does not know what she did wrong, but Resident 1 was crying about her toe. CNA 1 stated that she told Resident 1, "You cry about everything, me too." CNA 1 further stated that she never called the resident a cry baby and that she told her "Please don't cry, you're making me feel bad." According to CNA 1, she did not do anything wrong to Resident 1, but should have reported what happened to the charge nurse.
During a follow up interview on June 21, 2017, at 1:10 p.m., Resident 1 stated that she was "terrified" of using the lift and seeing CNA 1 after the incident. Resident 1 stated that she "dreaded" being cared for by CNA 1 and this made her feel more depressed. According to Resident 1, she kept it inside and bore it until she could not anymore and finally told the staff about it. Resident 1 stated that she "finally reached her limit". Resident 1 further stated that she feels better and happier now that CNA 1 does not care for her anymore and feels "ok" to use the mechanical lift.
During an interview on June 21, 2017, at 1:43 p.m., LVN 1 stated that Resident 1 is doing better, happier, smiling, talking and interacting more since CNA 1 does not care for the resident anymore.
A review of the facility's policy and procedure titled "Resident Abuse Policy and Procedure" dated January 1, 2013, indicated the facility shall uphold resident's right to be free from verbal, sexual, physical, mental abuse, corporal punishment and involuntary seclusion. Residents shall not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals.
The facility?s failure to ensure that Resident 1 was free from verbal abuse by CNA 1 had a direct relationship to the health, safety, or security of the resident. |
| 970000077 |
South Pasadena Care Center |
950013334 |
B |
10-Jul-17 |
F2G511 |
4747 |
? 483.13(c)(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
? 483.13(c) (3) The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress.
On 6/28/17, at 9:45 a.m., an unannounced visit was made to the facility to investigate an entity reported incident of alleged staff to resident abuse.
Based on interview and record review the facility failed to report to the State survey and certification agency (Department) within 24 hours of knowledge of Resident 1?s allegation of staff to resident abuse.
A review of the clinical record indicated Resident 1 was admitted to the facility on XXXXXXX17 with diagnoses that included unspecified atrial fibrillation (the atria or the upper chambers of the heart contract at an excessively high rate and in an irregular way) hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (type of ischemic [deficient supply of blood] stroke [sudden death of brain cells in a localized area due to inadequate blood flow] resulting from a blockage in the blood vessels supplying blood to the brain) affecting left dominant side and paranoid schizophrenia(a type of schizophrenia [mental disorder] associated with feelings of being persecuted or plotted against).
A review of Resident 1?s Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 5/26/17 indicated Resident 1 was cognitively intact. Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) to total dependence (full staff performance) in performing activities of daily living.
On 6/28/17 at 10:00 a.m., an interview was conducted with the director of nursing (DON). The DON stated on 6/2/17, Resident 1 reported to the local ombudsman an allegation that a female staff physically abused him but the resident could not remember the date and time the incident happened nor the name of the staff involved. The DON stated Administrator 1 immediately conducted an investigation on 6/2/17 following Resident 1?s allegation. The DON stated after Administrator 1 gathered all information, Administrator 1 concluded that the incident was not reportable to the Department. The DON stated as a mandated reporter, the facility must report all allegations of abuse to the Department. The DON stated that Administrator 1 insisted not to report to the Department. The DON stated she should have reported the incident to the Department. The DON stated Administrator 1 was replaced by Administrator 2 as of 6/26/17. Administrator 2 called the ombudsman?s office to introduce himself. The ombudsman inquired from Administrator 2 the status of the investigation regarding the allegation made by Resident 1 on 6/2/17. The DON stated Administrator 2 did not have any information regarding the above mentioned allegation made by Resident 1. The DON stated Administrator 2 instructed her to report the incident to the Department immediately on 6/27/17.
On 6/28/17 at 3:05 pm, an interview was conducted with Administrator 2 who confirmed the facility failed to report in a timely manner, a staff to resident allegation of abuse to the Department. Administrator 2 stated he was unaware of Resident 1?s allegation, until asked about it by the ombudsman. Administrator 2 indicated the previous administrator should have reported Resident 1?s allegation to the Department.
A review of the facility undated policy and procedure titled ?Abuse Reporting? indicated the administrator or DON will report the allegation of abuse to the appropriate state agency. The state agencies include: Department of Public Health Licensing and Certification, Nursing Home Administrator?s Program, Board of Vocational Nurses and Psychiatric Technicians and the CNA Certification Board, Adult Protective Services and Local Enforcement Agencies.
On 6/26/17 (after hours), the facility reported to the licensing department the staff to resident abuse that occurred on 6/2/17. The report was made 25 days after the incident occurred.
The facility failed to report to the Department within 24 hours of knowledge of Resident 1?s allegation of staff to resident abuse.
This violation had a direct relationship to the health, safety, or security of the residents. |
| 960002127 |
SUTTER HOUSE |
960009160 |
B |
21-Mar-12 |
11ZI11 |
4496 |
Title 22- 76931 (a) Each facility to which a client?s money or valuables have been entrusted shall comply with the following: (2) Each licensee shall maintain adequate safeguards and accurate records of clients? monies and valuables entrusted to the licensee?s care, including the maintenance of a detailed inventory. On February 9, 2012 at 5:30 a.m., an unannounced visit was made to the facility for a re-certification survey. Based on interview and record review the facility failed to: 1. Safeguard Client 2, 3, and 5?s money by failing to keep a full and complete account of personal funds for the clients. The facility deducted a total of $464.44 from the three client?s account with no documentation as to why the money was taken.According to the Face Sheet, Client 2 was admitted to the facility on July 1, 2006, with diagnoses including profound mental retardation, cerebral palsy, and seizure disorder. The client was observed to speak simple words such as: ?Yes, No, Juice,? etc. The client was ambulatory and depended on staff to meet her needs for activities of daily living. According to the Face Sheet, Client 3 was admitted to the facility on July 1, 2006, with diagnoses including moderate mental retardation, and chronic ear infection. The client was observed non-verbal but able to make his needs known via gestures and sign language. The client was ambulatory and depended on staff to meet his needs for activities of daily living. According to the face sheet, Client 5 was admitted to the facility on July 1, 2006, with diagnoses including profound mental retardation, cerebral palsy and seizures. The client was observed non-verbal; wheelchair bound and depended on staff to meet his needs for activities of daily living. On February 13, 2012 at 4:00 p.m., a review of the clients? Trust Account ledgers revealed the clients had discrepancies in their total running balance. The following was noted: 1. Client 2?s Trust Account Ledger dated November 3, 2011, had a balance of $420.75. There was a deposit on December 2, 2011 for $50.00 and the balance remained at $420.75. The facility failed to add the $50.00 deposit to the running balance. On January 4, 2012 a deposit of $50 was added to the client?s account and the balance changed to $470.75. 2. Client 3?s Trust Account Ledger dated December 2, 2011, had a balance of $565.52. There was a deposit on January 4, 2012 for $50.00 and the balance remained at $565.52. The facility failed to add the $50.00 deposit to the running balance. 3. Client 5?s Trust Account Ledger dated September 12, 2011 had a balance of $464.91.On October 19, 2011, one hundred dollars was taken from the clients account for clothing leaving a balance of $364.91. On November 7, 2011, the client had .47 cents deducted from his account because staff had spent $100.47 (October 19, 2011) on clothing. There was a negative balance documented of .47 cents. The balance from October 19, 2011, $364.91, was omitted from the client?s running balance. There was no supportive documentation provided by the facility as to why the money was taken from the client?s account. According to the ledger the facility had taken all the client?s money, leaving the client with a negative balance of .47. On November 20, 2011, $50.00 was deposited into the client?s account leaving a balance of $49.53. On December 19, 2011, $50.00 was deposited into the client?s account leaving a balance of $99.53. On January 17, 2011, $50.00 was deposited into the client?s account leaving a balance of $149.53 On February 13, 2012 at 4:20 p.m., during an interview with the Qualified Mental Retardation Professional (QMRP), she stated that accounting was responsible for the clients? ledger and ?it was a typo.? The QMRP confirmed that there were discrepancies in the clients? account balances and stated ?It?s got to be a typo.?On February 23, 2012 at 4: 30 p.m., further review of the clients? ledger indicated the QMRP signed off, by writing her initials, on each individual month of each client ledger for accuracy. The facility failed to safeguard Client 2, 3, and 5?s money and to keep a full and complete account of personal funds for the clients. The client?s money was entrusted to the facility. The facility deducted a total of $464.44 from the client?s account with no documentation as to why the money was taken. The above violation had a direct or immediate relationship to the client?s safety or security. |
| 630011598 |
St. Philomena Care Homes - I |
960012715 |
A |
15-Nov-16 |
0PFD11 |
8761 |
Title 22: 76878.1 Equipment and Supplies (a) (13) (a) Equipment and supplies in each facility shall be of the quality and in the quantity necessary for the care of clients as ordered or indicated. These shall be provided and properly maintained at all times and shall include at least the following. (13) Mobility assistive devices such as wheelchairs, walkers, canes and crutches as needed by clients and as indicated by the interdisciplinary professional staff/team. On 9/27/16, at 2:45 p.m., an unannounced visit was made to the facility to investigate an entity reported incident. The facility's administrative staff failed to maintain equipment in good repair for Client 1 by replacing, fixing a broken, non-working footrest. Client 1?s right wheelchair footrest could not be removed prior to the client being transferred. As a result, Client 1's right shin (lower leg) was rubbing against the footrest while staff transferred the client in and out of the wheelchair, creating multiples bruises and an open wound on the client's right shin. During an observation, on 9/27/16, at 3:00 pm, Client 1 was arriving from her day program via wheelchair. Client 1 is nonverbal, non-ambulatory and requires staff assistance for transferring and other activity of daily living. Client 1's right shin had one open wound and four bruises. A concurrent interview was conducted with a Direct Care Staff (DCS 1) regarding the open wound and bruises on Client 1's right shin and DCS 1 stated, "I don't know what happened." During an interview with the Licensed Vocational Nurse (LVN 1), on 9/27/16, at 3:20 pm, regarding the open wound and bruises on Client 1's right shin, LVN 1 stated she was not working on the day the incident occurred. LVN 1 stated DCS 2 would be able to answer the questions because she was the first staff who saw the open wound and bruises on Client 1's right shin. A review of Client 1's clinical record indicated the client was admitted to the facility on 4/20/16 with diagnoses of profound intellectual disability (significant developmental delays in all areas), cerebral palsy (a condition marked by impaired muscle coordination) with quadriplegia (full or partial loss of use of all four limbs) and right hemi-paresis (weakness on the right side of the body including the right arm and leg). During an observation, on 9/27/16, at 3:40 pm, DCS 3 transferred Client 1 from the client's wheelchair to her bed. DCS 3 could remove the left wheelchair footrest but could not remove the right wheelchair footrest. DCS 3 folded the bottom part (the square metal part) of the right wheelchair footrest up. The square metal part was placed at an angle pointed toward Client 1's right shin. DCS 3 proceeded to transfer Client 1 from the client's wheelchair to her bed. DCS 3 pointed to the square metal piece on the right wheelchair footrest and stated Client 1's right shin might have been scratched against the square metal part during transfer and caused the open wound and bruises. A review of the facility's communication book, dated 9/19/16, indicated DCS 2 noticed Client 1?s skin on the client's right shin was red. A review of the nurses' notes, dated 9/19/16, indicated there was no nursing assessment or investigation regarding Client 1's red skin on the client's right shin. A review of the facility's communication book, dated 9/22/16, indicated DCS 2 noticed Client 1 had an open wound on the client's right shin. A review of the nurses' notes, dated 9/22/16, indicated Client 1 had multiples bruises and a flap type skin tear, measuring 2.3 centimeter (cm) by 1 cm on the client's right lower shin area. A review of Client 1's first physician's order, dated 9/22/16, indicated to clean the right lower leg skin abrasion with normal saline (NS, salt solution/water) and apply Neosporin (antibiotic) ointment to the skin abrasion twice a day for 7 days. A review of Client 1's second physician's order, dated 9/22/16, indicated to monitor multiple bruises on Client 1's right shin area for 10 days. A review of the facility's communication book, entered on 9/24/16, by the Qualified Intellectual Disabilities Professional (QIDP), indicated Client 1's bruises and wound were resulting from staff not removing the client's footrest from her wheelchair. The QIDP also indicated for all staff to remove the wheelchair footrests completely before transferring the client. During a telephone interview with the facility's QIDP, on 9/27/16, at 3:55 pm, she stated Client 1's right wheelchair footrest could not be removed completely. The QIDP stated staff left the footrest in place while transferring Client 1 in and out of her wheelchair. The QIDP stated when staff lifted the right footrest (the square metal which supports the foot) up to put Client 1?s right foot on the floor; the foot rest part did not close completely. The QIDP stated the square metal part created a 30 degree angle rubbing against Client 1's right shin creating injury. The QIDP stated she asked the maintenance staff to lubricate (apply oil) the wheelchair footrests so it would be easier for staff to remove the footrests during transferring. The surveyor informed the QIDP that DCS 3 could not remove Client 1's right wheelchair footrest before transferring the client from the wheelchair to her bed and the QIDP stated the next step is to have the Physical Therapist (PT) evaluate Client 1's wheelchair. The QIDP stated when Client 1's right wheelchair footrest was in place during transferring, it was a risk for the client's right leg rubbing against the right foot rest and causing injury. The QIDP stated she completed the investigation and concluded that the right wheelchair footrest caused the injury on Client 1's right shin. The investigation report was faxed to the Department on 9/28/16. A review of the QIDP's investigation report, dated 9/28/16, indicated DCS 2 informed the QIDP that Client 1's wheelchair footrest was not flush when raised upward during a standing pivot transfer. Upon inspection of the footrest, the QIDP found that staff at the facility and at the day program was not removing the footrest completely when transferring the client. The footrest was at a 30 degree angle resulting in scraping and bruising Client 1's right skin. The footrest on the right was quite difficult to remove. The maintenance staff lubricated the mechanism on the footrest for easy removal; however the issue was not resolved. The QIDP indicated she contacted the PT to assist in resolving the issue with the wheelchair footrest. During an interview with DCS 2, on 9/27/16, at 4:15 pm, she stated on Tuesday, 9/22/16, at around 5:30 pm, after she transferred Client 1 from the wheelchair to the shower chair, she noted the client had an open wound on the client's right shin. DCS 2 stated she did not do a body check when Client 1 arrived from the day program at 3:00 pm; therefore, she did not know if the wound was created by the day program staff or it was created by the facility?s staff when they transferred Client 1 to the shower chair. During an observation, on 9/27/16, at 4:25 pm, Client 1's shin had one open wound and four bruises around the open wound. The open wound was covered with white exudate (liquid produced by body due to tissue damage). LVN 1 measured Client 1's open wound and bruises. The wound was measured at 2.4 cm x 1 cm. The four bruises were measured at 3 cm x 1.5 cm, 2.5 cm x 1.2 cm, 3 cm x 1.5 cm, and .07 cm x .06 cm. A review of the facility's undated policy and procedure titled "Moving a client from Bed to a Wheelchair," indicated to remove the footrest out of the way prior to transferring the client. A review of the facility's undated policy and procedure titled "Adaptive/Self-Help Devices and Equipment their Purpose and Use," indicated it is the facility's staff responsibility to know how to use the device and to keep it in good repair. The policy and procedure also indicated if there was a problem; notify the PT immediately to get it repaired. The facility's administrative staff failed to maintain equipment in good repair for Client 1 by replacing/fixing a broken/non-working footrest. Client 1?s right wheelchair footrest could not be easily removed prior to the client being transfer. As a result, Client 1's right shin (lower leg) was rubbing against the footrest while staff transferred the client in and out of the wheelchair, creating multiples bruises and an open wound on the client's right shin. The above violations presented either imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 960001670 |
STORM INN |
960013249 |
AA |
21-Jul-17 |
S9FT11 |
18678 |
Title 22, California Code of Regulations,
Section 76875 Health Support Services ? Nursing Services.
(a) Facilities shall provide registered nursing services in accordance with the needs of the clients for the purpose of:
(1) Training in personal hygiene, family life and sex education including family planning and venereal disease counseling.
(2) Development and implementation of a written plan for each client to provide for nursing services as a part of the individual service plan, consistent with diagnostic, therapeutic and medication regimens.
(3) Review and revision, as necessary, of the nursing services section of the individual service plan at least every six months.
(b) The attending physician shall be notified immediately of any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a client
Welfare and Institutions Code 4502
(a) 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.
(b) It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following:
(4) A right to prompt medical care and treatment.
On January 18, 2017 at 6:15 a.m., an unannounced visit was made to the facility to investigate an Entity Reported Incident (ERI) and a complaint regarding Client 1 dying in the facility.
Client 1 was found unresponsive in her bed at 6:30 am after having been last checked on by direct care staff (DCS) P at 3 am. At 3 am DCS P checked on Client 1 and found that she had defecated in her bed, but DCS P did not change her or clean her up. Then DCS F arrived in the morning and found her in her room unresponsive. At that point Client 1 had passed away.
The facility failed to provide Client 1 with necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with the comprehensive assessment and plan of care to meet the needs of the client including but not limited to:
1. Failure to call 911 after a change in condition when the registered nurse (RN) instructed DCS P to immediately call 911.
2. Failure of the RN to follow up and or perform an assessment after she was informed that Client 1 experienced a change in condition when Client 1 passed out on the floor of the bathroom.
3. Failure to follow up after the physician?s visit on January 7, 2017, regarding recommendations/orders for care of Client 1.
Failure of the facility?s DCS P and RN to provide care/services based on the client?s change in condition and recommendations/orders from the facility?s physician, which caused Client 1?s deterioration and death on XXXXXXX 2017.
A review of the clinical record for Client 1, a form dated September 12, 2016 and titled "Interdisciplinary Team Review Medical Assessment/Nursing," indicated Client 1 was admitted to the facility on XXXXXXX 1999 with diagnoses that included Downs Syndrome (a set of mental and physical symptoms that result from having an extra copy of chromosome 21), mitral valve insufficiency/prolapse (a weak or bulging mitral valve in the heart) congenital heart disease and profound intellectual disability (cognitive ability that is markedly below average level, incapable of self-care). Client 1 was non-verbal and ambulatory.
A review of a form titled "The Current Individual Support Plan," dated September 30, 2016, indicated Client 1 was able to walk independently, with a wide base and a slow pace. Client 1 was continent and used the bathroom with little staff monitoring other than to ensure she did not drink water from the sink.
During an interview with DCS P, on January 18, 2017 at 6:25 a.m., she stated Client 1 had been sick for more than 2 weeks with a cough and cold. DCS P stated Client 1 had not been eating well, falling onto the floor and not being able to get up without the assistance of two staff, and the client had pneumonia. DCS P stated on January 6, 2017 at 6:34 am, Client 1 was really sick, she stated the client was weak, pale, and could not walk. DCS P stated Client 1 fell to the floor when she walked Client 1 to the bathroom and she could not get Client 1 off the floor. DCS P stated she sent a group text to the administrator and RN/Licensee to inform them of the incident regarding Client 1's condition. DCS P said she was advised by the RN via text to take hourly vital signs and she did. DCS P said from 9 a.m., until 1 p.m., she took and reported vital signs to the group (administrator and RN/Licensee) by text. DCS P stated the RN directed her via text at 1:16 p.m., to call 911; instead she allowed Client 1 to rest and eat.
A review of a printed copy of the group text message dated January 6, 2017; indicated vital signs for Client 1 were as follows:
9 am - B/P 116/87, pulse 64, and temperature 99.3
10 am - B/P 77/50, pulse 85, and temperature 98.4
12 pm - B/P 83/51, pulse 68, and temperature 98.4
A review of an acute care hospital (ACH) form titled "Visit Information" dated November 8, 2016, indicated reason for visit for Client 1 was sepsis (infection usually affecting entire body), pneumonia (infection of lungs), and hypotension (low blood pressure). At the time of death Client 1 was taking the following medication, Levothyroxine 0.12 mg once a day to treat hypothyroidism, escitalopram 10 mg, risperidone 0.25 mg two times a day for psychosis, divalproex 250 mg three times a day, and gabapentin 300 mg three times a day for behavior management.
Review of a form titled ?Licensed Nurses Notes,? was the last nursing note by the RN, dated November 9, 2016, indicated Client 1 was admitted to the general acute care hospital (GACH) after staff observed her to have generalized weakness on November 5, 2016.
The paramedics transported the client to the hospital for evaluation. Client 1 was diagnosed with sepsis, hypotension and altered mental status (mildly depressed level of consciousness or alertness may be classified as lethargy). Procedure done: chest x-ray, EKG, swallow evaluation, blood test, and urinalysis. Client 1 was readmitted back to the facility on XXXXXXX 2016 with a prescription for levofloxacin 500 mg 1 tablet daily for 6 days and metronidazole 500 mg 1 tablet three times a day for 6 days (both medications are antibiotics for treatment of infection). Continued review of the nurse?s notes indicated there was no documentation by the RN for the incidents that occurred on January 6th and January 9th of 2017, regarding a change in condition for Client 1.
A review of a complaint dated January 12, 2017 from the Regional Center (RC, state agency that provide services for individuals with intellectual disabilities) regarding the death of Client 1, indicated the facility's physician made a visit on January 7, 2017 and did an assessment of Client 1. Documentation indicated DCS F reported to the facility's physician that Client 1 had a change in condition that occurred on January 6, 2017. Further review indicated the facility's physician noted Client 1's weight gain. According to the RC documentation, the facility's weight chart for Client 1 was noted to be 136 pounds in December 2016. The physician's note stated Client 1's weight for January 7, 2017 was 146 pounds, 10 pound weight gain in one month. Continued review of the RC report indicated the following: Client 1 was not visited by the facility nurse or Qualified Intellectual Disabilities Professional (QIDP) over the weekend; all communication with staff regarding Client 1 was done over the phone or via text.
Further record review of a form titled "Adult Progress Note/Homes" completed by the physician, dated January 7, 2017, indicated the facility's physician made a visit to the facility. The following was indicated regarding Client 1: chief complaint and history; lethargic, yesterday had hard time getting up, #4 Assessment indicated MVP (mitral valve prolapse), no CHF (congestive heart failure, the inability of the heart to pump blood efficiently), noted increased weight gain (146 pounds). The plan was to see cardiologist, staff to monitor client weight gain and lethargy. The following laboratory tests were ordered: BMP (basic metabolic panel, blood work to check the blood chemistry regarding multiple items such as potassium, sodium, glucose) and CBC (complete blood count). Continued review of the form indicated no additional documentation or initials by the RN indicating she reviewed the form or that she was aware of the recommendations/orders.
During an interview with DCS P, on January 18, 2017 at 6:25 a.m., DCS P stated the next incident occurred January 9, 2017 after 10 pm, DCS P stated Client 1 began to display the same type of weak behavior that she displayed on January 6, 2017, but this time the client was in the bathroom on the floor and was too weak to walk independently to her bedroom. DCS P stated Client 1 remained on the floor for a long time until a staff from another facility came and assisted her to get the client off of the bathroom floor. DCS P stated she called the RN and told her the client fell on the floor in the bathroom and the RN told her she would find a staff from another facility to provide assistance for her. DCS P stated with the assistance of another staff, they removed the client from the floor and placed her in the bed. DCS P stated when Client 1 was in bed she was quiet, weak and very sleepy. DCS P stated she checked on Client 1 at midnight on January 10, 2017 and then again at 3 am. DCS P stated when she walked in Client 1's bedroom she smelled urine and feces (at 3:00 a.m.). DCS P stated when she looked at Client 1 she had defecated everywhere in the bed. Staff P stated she did not clean the client up, instead left her in the bed until the morning. DCS P stated she did not remove the feces and urine because Client 1 was too heavy and she needed assistance from staff to lift the client from the bed. DCS P stated she did not look at Client 1 again until DCS F arrived to assist her at 6:30 a.m. DCS P stated after all of the clients were bathed, fed, ready and waiting for the bus to arrive, she entered Client 1's bedroom at 6:30 a.m., to find her laying on her face with her tongue hanging out of her mouth. DCS P stated she tapped Client 1 on the shoulder, called her name several times but Client 1 did not respond. DCS P stated she knew something was wrong and she called the administrator and told her Client 1 would not wake up (unsure of the time she called). DCS P stated she attempted to take Client 1's pulse but could not feel anything. DCS P stated at 6:30 a.m., she called for the assistance of DCS F and when he arrived in the bedroom, DCS F attempted to take Client 1's blood pressure twice but the machine did not work. DCS P stated it was then that DCS F took over, and called 911, they both placed Client 1 on the floor, and she stepped out of the room to care for the other clients. DCS P stated when the bus arrived DCS F stopped doing cardiopulmonary resuscitation (CPR) on Client 1 to take the clients to the bus and she took over providing abdominal thrust (demonstrated placing her balled hand in the center of the abdomen and pushing upwards) to Client 1 until DCS F returned from the bus. DCS P stated she was sorry for not calling 911 the first time Client 1 collapsed on the floor and it was her fault. DCS P stated she should have known something was wrong when Client 1 defecated on herself because she was toilet trained. DCS P stated she did not check on the client hourly as she was supposed to according to the direction which was given to her by the administrator when she was hired. DCS P stated she called the RN after the paramedics left the facility and informed her that Client 1 had died.
During an interview with DCS F, on January 18, 2017, at 6:51 am, he stated on the morning of January 10, 2017 he arrived to work late and upon his arrival he immediately began preparing the other clients for the day. He stated he provided morning care to the other clients that included bathing, oral care, dressing the clients for the day, giving breakfast and administrating medication, for the male clients only. DCS F stated he went into Client 1's bedroom at 6:30 am, to assist DCS P change Client 1's bedsheets and dress her for the day. DCS F stated when he walked into the bedroom he saw Client 1 laying on her face with her tongue hanging out of her mouth and purplish/pale in the face, he stated he knew something was wrong, there was a problem, and it was bad. He stated he removed the blanket and saw poop everywhere, all over the sheets, blankets and bed. DCS F stated he tried to take Client 1's blood pressure three (3) times but the machine did not work, then he tried to take Client 1's pulse on the wrist but was not able to get a pulse at all. He called 911 but he kept getting disconnected. He ran to the bathroom, retrieved tissue; put the tissue on top of Client 1's face and nose to see if she would move but the tissue did not move DCS F said that was his way of checking to see if the client was breathing). DCS F retrieved the land line phone and called 911 again. He then put the client on the floor, and started chest compressions. DCS F stated he stopped doing compressions to get Client 2 on the bus, but was slowed down by Client 2 who would not cooperate and was moving slow to load the bus. DCS F stated he returned to perform chest compressions after Client 2 left and kept doing chest compressions until emergency help arrived. DCS F stated when the paramedics arrived they connected Client 1 to a monitor and then informed the staff that Client 1 was dead. DCS F stated hours later the mortuary arrived and took her body away. DCS F stated maybe he was not doing chest compressions hard enough or maybe he should have sat on her stomach, he was not sure. DCS F stated he wished DCS P would have helped her when she realized she had pooped on herself.
During an interview with the RN/Licensee, on January 18, 2017 at 11:41 am, she stated when she received the phone call from the Administrator on January 10, 2017 (not sure of the time) that Client 1 was in acute distress she was surprised because she directed DCS P to call 911 January 6, 2017, when the client passed out on the floor in the bathroom. The RN stated staff should have known something was wrong with Client 1 when the client defecated on herself because she was toilet trained. The RN stated she did not follow-up to see if Client 1 had gone to the hospital. The RN stated because she was caring for her mother as well and dealing with her own health issues.
A review of the RN duties indicated the RN is contracted to visit the facility for health services and client health assessment as needed but no less than one hour per client per week. The RN has the authority to carry out the following nursing functions:
1. Make judgments regarding client health issues within the scope of the Nurse Practice Act.
2. Participate in pre-admission and evaluation
3. Periodic evaluation of services
4. Provide evaluation of services at least every six months
5. Teach the medication administration
6. Certify and document staff proficiency in writing
The Prehospital Care Report Summary (paramedic report) dated January 10, 2017, indicated a call was received at 6:39 a.m., the paramedic arrived at the facility at 6:47 a.m., Client 1 was observed with rigor mortis (one of the recognizable signs of death, caused by chemical changes in the muscles after death, causing the limbs of the corpse to stiffen), lividity (black and blue in color, one of the signs of death) body was cold to the touch, no pupillary response (physiological response that varies the size of the pupil), no apical pulse, and no lung sounds.
According to the death certificate received XXXXXXX 2017, Client 1 died due to a cardiopulmonary arrest.
The policy and procedure titled ?Urgent Call to the Doctor,? indicated the following are examples that require an urgent call to the doctor:
New or sudden onset of incontinence.
Diarrhea or vomiting lasting more than four hours.
Onset of limping, inability to walk, or difficulty in movement.
Always report these changes to the doctor as soon as possible. When in doubt, call the doctor. When you call the doctor, stay on the phone until you get assistance. If you think the doctor did not understand how serious the situation is or if it gets worse, call 911. Your actions can save a life.
Policy and procedure titled ?What to do When you Learn About a Change,? Once you identified a change you must make a decision on what action you should take. Making the right decision involves using all of your knowledge about the person, and his or her health history, current medications and doctor?s orders. Signs and symptoms of illness will have different levels of response, which include the following:
911 call: medical emergencies that require immediate medical attention.
The facility failed to provide Client 1 with necessary care and services to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with the comprehensive assessment and plan of care to meet the needs of the client including but not limited to:
4. Failure to call 911 after a change in condition when the registered nurse (RN) instructed DCS P to immediately call 911.
5. Failure of the RN to follow up and or perform an assessment after she was informed that Client 1 experienced a change in condition when Client 1 passed out on the floor of the bathroom.
6. Failure to follow up after the physician?s visit on January 7, 2017, regarding recommendations/orders for care of Client 1.
Failure of the facility?s DCS P and RN to provide care/services based on the client?s change in condition and recommendations/orders from the facility?s physician, which caused Client 1?s deterioration and death on XXXXXXX 2017.
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 and was a direct proximate cause of the death of the client. |
| 960002314 |
SUNDANCE HOUSE |
960013250 |
A |
5-Jul-17 |
KJKN11 |
6023 |
Title 22: 76918 Client?s Rights
(a) Each client shall have those rights as specified in Sections 4502 through 4505 of the Welfare and Institutions Code and Sections 50500 through 50550 of Title 17 of the California Code of Regulations.
W&I 4502
(a) 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. An otherwise qualified person by reason of having a
developmental disability shall not be excluded from participation in,
be denied the benefits of, or be subjected to discrimination under any
program or activity that 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 May 8, 2017, an unannounced visit was made to the facility to investigate an entity reported incident (ERI) regarding a client found on the floor and sustaining a broken right arm.
The facility staff failed to:
Ensure the side rail was in a raised position while Client 1 was in bed. This failure resulted in the client falling out of bed and sustaining a broken arm.
The Department of Public Health received an ERI from the facility on April 24, 2017 indicating direct care staff (Staff A) went into Client 1's bedroom, on April 20, 2017 during the night shift, and found the client on the floor. The report indicated the qualified intellectual disability professional (QIDP) instructed Staff A to contact 911.
During a review of the Admission Face Sheet, indicated Client 1 was admitted to the facility XXXXXXX 2011 with a diagnosis of Profound Intellectual Disability (significant developmental delays in all areas and incapable of self-care).
During a review of the "Physical Therapy Annual Evaluation" dated January 26, 2017, indicated Client 1 is independent for bed mobility when he is motivated, but mostly, the client needs verbal cueing and manual assist for direction and to ensure safety.
During a review of the Occupational Therapy Annual Report, dated February 11, 2017, indicated Client 1, while seated in wheelchair, presented poor safety awareness with moving too close to edge of chair and reaching forward, and that the client required assist to move into a safe position.
During an interview with Staff A, on May 8, 2017 at 8:50 a.m., he stated during the night shift, he lowered Client 1's side rail to check if the client needed changing, and then exited the room forgetting to raise the side rail. Staff A stated afterwards, he heard a noise from the client's room, and that is when he found Client 1 on the floor. Staff A stated the client's right arm was moving loosely like "jello."
During a review of the "QIDP Notes" dated, April 20, 2017, indicated Staff A notified the QIDP that Client 1 was found on the floor on April 20, 2017 at 12:30 a.m.
During a review of the "Licensing and Certification Declaration" dated May 8, 2017, Staff A wrote he put Client 1's side rail down to check on the client, and when he was done checking Client 1 he forgot to put the side rail back up.
During a review of the "Physician's Orders" dated June 1, 2016, indicated for Client 1 to have padded side rails up for safety.
During an interview with Staff B, on May 8, 2017 at 9:51 a.m., she stated she pulls the side rail up when Client 1 is in bed to prevent him from falling out of bed because he does move while in bed.
During an interview with the QIDP, on May 8, 2017 at 11:49 a.m., she stated the side rail is for safety and to keep Client 1 from rolling out of bed. The QIDP further stated staff are to raise the side rail when the client is in bed.
During a review of the acute care hospital's "Emergency Department Discharge" form, dated April 20, 2017, indicated Client 1 was found in the evening with the side rail down, staff thinks that the side rail was accidentally left down, and the client was found on the floor. The hospital form also indicated Client 1 had a right midshaft humerus fracture (broken bone of the upper arm), a sling and swathe was applied, and the client was sent home stable with instructions to follow up with orthopedics (branch of medicine concerned with conditions involving the musculoskeletal system) within a week.
During a review of the in-service training record for "Bed Rail Safety" dated March 2017, indicated bed rails are used to protect clients from falling out of bed, bed rails are used if there is a doctor's order, and bed rails are used if the client moves around in bed and does not have the physical or cognitive ability to not fall off the side of the bed. The in-service record also indicated Staff A received the training.
During a review of the care plan "Alteration in Comfort: Pain" dated April 20, 2017, indicated Client 1 had actual pain related to right humerus fracture.
During a review of the medication administration record (MAR) for the month of April 2017, indicated facility staff started giving the following pain medications to Client 1 on April 20, 2017: Tylenol 650 milligrams (mg) 3 times on April 20, 2017, once on April 21, 2017, twice on April 24, 2017, twice on April 25, 2017; Norco 5-325 mg (narcotic medication to relieve moderate to severe pain) once on April 25, 2017, once on April 26, 2017, and once on April 27, 2017.
The facility staff failed to:
Ensure the side rail was in a raised position while Client 1 was in bed. This failure resulted in the client falling out of bed and sustaining a broken arm.
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. |
| 960001677 |
SPECIAL ADULT CARE HOME |
960013298 |
B |
20-Jun-17 |
651R11 |
7610 |
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 development disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds.
It is the intent of the Legislature that person with developmental disabilities shall have rights including, but not limited to, the following:
(h) Right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect.
On April 17, 2015, an unannounced visit was made to the facility to conduct an investigation regarding an entity reported incident concerning Client 4?s elopement from the home on April 9, 2015. A complaint investigation was also initiated concerning Client 4?s second elopement from the home on April 15, 2015, whereas the client was found walking on local freeway lanes at 6:40 a.m.
On April 10, 2015, the Department received a reported incident from the facility indicating on April 9, 2015 around 4 a.m. to 5 a.m., Staff A noticed Client 4 was absent from the facility. And at 5:30 a.m., Staff A notified the qualified intellectual disability professional (QIDP) that Client 4 was not present in the facility.
On April 15, 2015, the Department received a complaint indicating on April 15, 2015 at 6:40 a.m., Client 4 was found walking on local freeway lanes and this was the second occurrence of the client leaving the facility. The complaint also indicated Client 4 was then taken to the hospital and placed on a 5150 hold (involuntarily hospitalized in a psychiatric hospital for up to 72 hours for being gravely disabled, or a danger to self, or a danger to others).
The facility failed to:
Ensure supervision and hourly checks were done regarding the elopement risk for Client 4. This failure resulted in Client 4 eloping from the facility and found walking on freeway lanes by the local police department.
During a review of the clinical record for Client 4, the Admission Face Sheet indicated the client was admitted to the facility on XXXXXXX 2015, with a diagnosis of moderate intellectual disability (developmentally functions below chronological age and can learn elementary health and safety habits). The "Monthly Nursing Summary" dated April 29, 2015, indicated the client had two episodes of elopement from the facility, and was unable to express reasons why he left the facility due to his mental/cognitive current status.
During an interview with the QIDP, on August 3, 2015 at 2:02 p.m, she stated during the incident on April 15, 2015, the video surveillance captured a video of Client 4 walking pass the kitchen into the recreation room where he waited briefly, then walked pass the kitchen towards the front door, and exited the facility. The QIDP stated overnight staff is expected to be in the recreation room, and it was concluded Staff A must have been asleep to not have noticed Client 4 walking into the recreation room.
During a subsequent interview with the QIDP, on August 6, 2015 at 1:10 p.m., she stated the staff were not given training nor was a plan established upon admission for Client 4's AWOL/elopement risk because she was unaware the client had a history of elopement. The QIDP stated the AWOL plan was started after the client's first elopement episode on April 9, 2015.
According to the ?Medication Error/Incident Report? dated April 9, 2015, indicated Client 4?s absence from the facility was discovered around 5 a.m. The report indicated the client was found and returned to the home around 9:45 p.m. on XXXXXXX 2015. The report further indicated a corrective action plan that included installation of door alarms on all entrances and exits in the home, as well as institution of a home survey log requiring the overnight staff to conduct hourly checks to ensure clients? presence and safety.
During a review of the ?Vendor Special Incident Report? dated April 9, 2015, indicated Client 4?s absence from the facility was discovered around 4 a.m. to 5 a.m., and the preventive action plan included the installation of door alarms, as well as the development of an overnight shift log to ensure staff are making rounds on a regular basis.
During a review of the "Vendor Special Incident Report" dated April 15, 2015, indicated Staff A reported he fell asleep during his shift. The report also indicated Staff B awakened Staff A on April 15, 2015 at approximately 6 a.m., and then there was a discovery Client 4 was not present in the facility.
During a review of Staff A's "Job Description: Programmer/Direct Care" dated April 17, 2014, indicated the facility is dedicated to working with adults having moderate to severe intellectual disability who have deficits in self-help skills, communication, sensory-motor skills, socialization, behavioral functioning, and will require a setting in which intensive 24-hour supervision is available. The job description also indicated Staff A will provide daily supervision of moderate to severe intellectually disabled clients exhibiting behavioral problems with the intention of preventing any physical or emotional harm to clients.
During a review of the psychologist's "Behavioral Assessment" dated March 27, 2015, indicated per a Psychological Evaluation, dated June 12, 2013, Client 4 has a history of elopement. The "Behavioral Assessment" also indicated in a report from regional center, dated June 12, 2014, that Client 4 has a history of AWOL. The "Behavioral Assessment" further indicated in a report from the Department of Developmental Services, dated October 20, 2014, Client 4 has a history of wandering away.
During a review of the "Consultant Agreement" for the QIDP undated, indicated the QIDP agrees to participate in the pre-admission evaluation and discharge plan, and will periodically re-evaluate the type, extent, and quality of services and programming.
During a review of Staff A's employee file, the "Documentation of Verbal Warning" dated April 9, 2015, indicated Staff A failed to follow emergency procedures to inform the appropriate parties immediately during an emergency situation. The document also indicated Staff A did not call the QIDP or emergency services immediately when Client 4 was discovered missing.
During a review of the policy titled "Procedure for Conducting Search" undated, indicated when a facility client is noticed to be missing, an immediate search of the facility premises will take place and to notify the local police, and the QIDP.
During a review of the "Employee Warning Report" dated April 16, 2015, indicated Staff A neglected to complete assigned duties of routine hourly check of all areas and rooms of the home during the night shift to ensure clients' safety. As a result of reviewing footage from security cameras it was determined that Staff A was asleep while on duty, resulting in Client 4's absence without leave (AWOL). Staff A was given a two week suspension as a consequence.
The facility failed to:
Ensure supervision and hourly checks were done regarding the elopement risk for Client 4. This failure resulted in Client 4 eloping from the facility and found walking on freeway lanes by the local police department.
The above violation had a direct relationship to the health, safety, or security of patients. |
| 630011744 |
Scoville Villa |
960013461 |
B |
31-Aug-17 |
FDS611 |
7911 |
California Code of Regulations, Title 22, ?76874 Health Support Services ? Physician Services
(d) The physician, clinical psychologist, podiatrist or dentist shall record progress notes and make other appropriate entries in the client record upon each appointment with the client.
On July 17, 2017 at 5:50 AM, an unannounced annual Fundamental Recertification Survey was conducted.
The facility failed to:
Ensure the podiatrist recorded accurate and appropriate assessments on the progress notes over the period of one year for 6 clients (Clients 1, 2,3, 4, 5, and 6). The podiatrist documented the same information after each visit to the facility for each client over a period of one year. There were no improvements or treatments noted by the podiatrist. This deficient practice has the potential to result in inaccurate, erroneous records and lack of care/services for the clients.
During a review of the clinical records for Clients 1, 2, 3, 4, 5, and 6, on 7/19/2017, each client had a section in their medical records for Podiatry services. Clients 1, 2, 3, 4, 5, and 6 had Physician's Progress Notes documented by the Podiatrist on 7/6/2017, 5/4/2017, 3/2/2017, 1/5/2017, 11/3/2016, 9/8/2016, and 7/14/2016. Clients 2 and 5 had an additional note on 5/12/16 in their medical records. Each date had its own separate page for every client. Each page for each date was a photocopy with identical information used for each client, including the podiatrist signature. The name of the client and the date was written in pen on the progress note in order to separate what was copied and was written. The notes indicated the following:
-S (Subjective): "Pt (patient) presents stating my toenails are all painful and long, I need help with my nail care."
-O (Objective): "Pt presents c (with) elongated dystrophic mycotic toenails 1-5 feet bil (bilaterally)."
-A (Assessment): "Mycotic dystrophic toenails 1-5 feet bil."
-P (Plan): "Good obtained nails 1-5 feet bil debrided (the removal of tissue) R/B (return back) 2 months."
According to an article published by the Cleveland Clinic on 3/3/2017 titled "Mycotic Nails," the article indicates "Mycotic nails are nails that are infected with a fungus. The nail may be discolored, yellowish-brown or opaque, thick, brittle, and separated from the nail bed. In some cases the nail actually may be crumbly." The article indicated "Mycotic nail infections are difficult to treat. [ ...] Two standard forms of treatment are available: antifungal creams, lotions, and gels can be applied to the affected area. Treatment can last several weeks and maintaining a fungus-free nail requires long-term use. Antifungal pills (oral medication) can cure an infection but have dangerous side effects [ ...] thus, they are only used when the infection is severe or difficult to treat."
During a review of the clinical record for Client 1, on 7/19/2017, the Face Sheet indicated Client 1 has a diagnosis of profound intellectual disability (cognitive ability that is markedly below average level, incapable of self-care).
The Speech Therapy Annual Evaluation Report , dated 6/7/2017, indicated under Receptive Communication "Client 1 is able to answer simple yes/no questions regarding her basic needs and wants with 60% accuracy. ?Client 1 is inconsistent in responding to Wh-questions appropriately?. The Speech report indicated under Expressive Communication "Client 1 is able to adequately express simple, rote social greetings, including "Hi," "Bye," and "Thank you." According to the Speech Report, Client 1 is able to verbalize simple ideas related to her state, at the word or phrase level, i.e. "Dinner?," "I'm cold," however Client 1's verbalizations can be inappropriate or tangential (means of little relevance) in nature."
During a review of the clinical record for Client 2, on 7/19/2017, the Face Sheet indicated Client 2 has a diagnosis of moderate intellectual disability (developmentally functions below chronological age and can learn elementary health and safety habits).
The Comprehensive Function Assessment, dated 9/1/2016, indicated under Speech and Language Skills that Client 2 sometimes speaks in 2 word sentences.
During a review of the clinical record for Client 3, on 7/19/2017, the Face Sheet indicated Client 3 has a diagnosis of profound intellectual disability.
The Comprehensive Functional Assessment, dated 8/14/2016, indicated under Speech and Language Skills that Client 3 cannot verbalize words, cannot state his name and uses unintelligible vocalizations.
During a review of the clinical record for Client 4, on 7/19/2017, the Face Sheet indicated Client 4 has a diagnosis of severe intellectual disability (cognitive ability that is markedly below average level and a decreased ability to adapt to one?s environment).
The Comprehensive Functional Assessment, dated 12/22/2016, indicated that Client 4 uses unintelligible vocalizations and cannot state his name or speak one or more word sentences.
During a review of the clinical record for Client 5, on 7/19/2017, the Face Sheet indicated Client 5 has a diagnosis of profound intellectual disability.
The Comprehensive Functional Assessment, dated 3/30/2017, indicated Client 5 makes unintelligible vocalizations and is unable to verbalize single words or speak in sentences of two or more words.
During a review of the clinical record for Client 6, on 7/19/2017, the Face Sheet indicated Client 6 has a diagnosis of mild intellectual disability (developmentally functions below chronological age, is slow in all areas, but can acquire practical and vocational skills).
The Comprehensive Functional Assessment, dated 1/26/2017, indicated Client 6 is able to state his name and speak in 4 or more word sentences.
During an interview with the Registered Nurse (RN), Licensee, House Manager, and Qualified Intellectual Disability Professional (QIDP), on 7/19/2017, at 3:00 PM, they confirmed that all the clients had the same note that had been photocopied and re-used for all the clients. The RN and Licensee stated that they did not read any of the Podiatrist's Progress Notes. The Licensee stated that she places the notes from the Podiatrist in each of the clients? medical records when the Podiatrist provides it to her during every visit. The RN stated that she would only have reviewed the Podiatrists Progress Notes if he were to have recommended new orders. The RN stated that she was not aware of any orders from the Podiatrist.
During an observation with the RN, on 7/19/2017, at 3:50 PM, Clients 3, 4, and 6 did not have any signs indicative of mycotic, dystrophic toenails. The toenails for each of these clients did not have any chipping, discoloration, or malformation. Clients 3,4, and 6?s nailbeds were observed clean and clear on both feet. An observation at 3:53 PM, Client 1 had yellowish-white discolorations, and malformations on the toenails of both of her feet. Another observation at 3:55 PM, Client 5 had thick, yellow-white discolorations and malformations on his toenails. A final observation at 3:58 PM, Client 2 had some nails with yellow-white discolorations, mild chipping and mild malformations of his toenails on both feet.
The facility failed to ensure the podiatrist recorded accurate and appropriate assessments on the progress notes over the period of one year for 6 clients (Clients 1, 2, 3, 4, 5, and 6) . The podiatrist documented the same information after each visit to the facility for each client over a period of one year. There were no improvement or treatments noted by the podiatrist. This deficient practice has the potential to result in inaccurate, erroneous records and lack of care/services for the clients.
The above violation had a direct relationship to the health, safety and security of the clients residing in the facility. |
| 970000174 |
Serenity Care of Pasadena |
970009181 |
B |
26-Mar-12 |
1F1L11 |
18135 |
483.35(i)(1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and 483.35(i) (2) Store, prepare, distribute and serve food under sanitary condition The Department received an anonymous complaint on February 14, 2012, regarding a complaint about dietary services. On February 17, 2012, at approximately 6:50 a.m. an unannounced visit was made to the facility to investigate the complaint. Based on observation, interview, and record review, the facility failed to:1. Follow its policy in serving residents only pasteurized eggs. 2. Ensure residents were served food that was prepared following safe food handling procedures to ensure food safety and prevent potential for foodborne illness, which was identified for four of four residents (Resident 1, 2, 3, and 4). 3. Check all food temperatures prior to serving the food trays to the residents to ensure proper and acceptable food temperature as per the facility?s policy. 4. Monitor food temperatures and functioning of the refrigeration equipment daily as per its policy. 5. Properly store, prepare, and serve food under sanitary conditions to ensure food safety and prevent potential for foodborne illness for residents in the facility.a. During an initial tour of the facility's kitchen on February 17, 2012, at approximately 6:50 a.m., one full flat and twenty-four (total of 60) unpasteurized eggs were observed stored on the bottom shelf of the refrigerator. A concurrent interview with the cook regarding the unpasteurized eggs indicated she knew not to use unpasteurized eggs and stated "My supervisor director of dietary services instructed all the staff to use these eggs and she does all the ordering of the eggs." On February 17, 2012, at approximately 7:25 a.m., four plates with covers containing nine over-easy eggs was observed on top of a cold grill. At this time, the cook was asked when the over easy eggs were cooked, she stated at 6 a.m. that morning. On February 17, 2012, at approximately 7:40 a.m., during a trayline observation, one of the two food carts had already left the kitchen. When the cook was asked, what happened to the food cart, she stated, "We took the food out to serve it to the residents." When asked if she had checked the temperature of the food, she stated, "No." At this time, the surveyor asked the cook to check the temperature of the over-easy eggs, french toast, oatmeal, and milk on the second food cart. The thermometer read: 1. Eggs- 90 degrees F 2. French toast- 130 degrees F 3. Oatmeal- 106 degrees F 4. Milk- 50 degrees F A review of the facility's undated policy, titled, "Food Preparation," indicated eggs should be cook until the white and yolk are firm, not runny." According to the policy the eggs should be at 140 degrees F, french toast at 140 degrees F, oatmeal at 140 degrees F, and the milk no more than 41 degrees F.On February 17, 2012, at approximately 7:50 a.m., after the surveyor asked the cook to confirm the temperatures of the food on the second cart, the kitchen staff stood around unsure what to do with the food. The dietary staff asked the survey team what they should do with the food. The cook then responded, "Let me check with the director of nursing (DON)." An interview on February 17, 2012, at 8 a.m., Resident 1 who had consumed two unpasteurized undercooked over easy eggs that morning, stated," I don't like the food here, it's always cold."A review of a Resident Council Meeting minutes, dated April 8, 2011 and May 15, 2011, indicated residents complained about the food being too cold when they received it. According to the notes in the minutes, no suggestions were indicated by the facility staff to resolve or address the issue about the complaint of residents receiving their food cold.On February 17, 2012, at approximately 8:05 a.m., the kitchen staff was observed re-cooking the seven unpasteurized eggs over-easy for the second cart after the director of nursing (DON) instructed them to re-cook the eggs again. The staff was stopped, after rolling cart out of the kitchen, and the cook was asked to check the temperature of the eggs. The thermometer read 100 degrees F. According to the facility's policy dated 2011, titled, "Food Preparation," indicated only pasteurized eggs (shelled or liquid) must be used. According to the 2009 "Food Code" published by the Food and Drug Administration (FDA), EGG PRODUCTS shall be obtained pasteurized. Raw animal FOODS such as EGGS, FISH, MEAT, POULTRY, and FOODS containing these raw animal FOODS, shall be cooked to heat all parts of the FOOD to a temperature and for a time that complies with one of the following methods based on the FOOD that is being cooked: 145 degrees F or above for 15 seconds for: (a) Raw EGGS that are broken and prepared in response to an order and for immediate service." On February 17, 2012, at 9:05 a.m., the cook stated she knew since 2004 that only pasteurized (heat treated in order to destroy harmful bacteria) eggs should be used when preparing undercooked egg yolk. When asked if she knew the danger of not cooking the unpasteurized eggs well she stated, "The residents can get really sick." When the cook was asked if she had been inserviced about the importance of maintaining the proper temperatures of hot and cold food she stated, "Yes." A review of the in-service trainings on proper food handling and monitoring safe food temperature, dated between June 13, 2007 to February 9, 2011, indicated the cook and other kitchen staff had received in-service training twelve times during that period. The in-services included proper temperatures of hot foods and cold foods for meal preparation and service, which included the importance of checking the temperature of the food prior to serving to the residents and logging it in the temperature log sheet for monitoring purposes.In an interview, on February 17, 2012, at 9:45 a.m., the director of dietary services (DDS) was asked if she was aware unpasteurized eggs should not be cooked over-easy and what the proper temperature should be. The DDS acknowledged it was unacceptable to cook unpasteurized eggs runny and stated the temperature of the eggs should be at least 140 degrees F. The DDS was also asked why the facility was using unpasteurized eggs she stated, "We were trying to cut cost."On February 17, 2012, at 10:18 a.m. an interview was conducted with the registered dietitian (RD). The RD consultant stated, "It's dangerous for the facility to serve unpasteurized eggs that isn't cooked well because residents can get Salmonella and have diarrhea." The RD stated she informed and trained the dietary staff about using pasteurized eggs when preparing eggs over-easy. She also stated she sometimes randomly watch the meal service traylines, but not for the breakfast meal. When asked if she was aware the facility was using unpasteurized eggs she stated, "No, it's hard to tell the difference between pasteurized and unpasteurized eggs." When the RD was asked if pasteurized eggs have a stamp on them, she stated, "Yes." The RD stated, "I only work six hours a month and have told the administrator in the past that I needed more hours in order to do my job properly." The RD also stated, "The facility is accepting residents with a higher acuity (level of care) now, so I can't do my job properly with so few hours a month.? Furthermore she stated, ?I understand there are systems problems and I have requested for more hours, in order to oversee the kitchen closer." On February 17, 2012, after the administrator was apprised of the IJ, she stated she was aware that unpasteurized eggs are not to be used for cooking over easy eggs because she received the All Facility Letter (AFL) back in 2003 or 2004. A review of the "All Facilities Letter" (AFL 03-12) issued by the California Department of Health Services on March 19, 2003 indicated, "This letter detailed specific direction that facilities may not accommodate resident's personal requests by serving undercooked eggs due to the risk of exposure for residents to toxigenic microorganisms such as Salmonella. The FDA and the American Egg Board continue to caution against eating raw or undercooked eggs. With the availability of pasteurized shell eggs to the California market place, resident rights may be honored by providing eggs with undercooked yolks or yolks that have not been cooked to the temperature of at least 140 degrees F for three minutes or 145 degrees F for 15 seconds, provided that a pasteurized product is used." A review of food invoices presented, indicated October 4, 2011 was the last time the facility ordered pasteurized eggs. During an interview, on February 17, 2012, at 12:05 p.m., the registered nurse (RN 1) stated Resident 1 complained of diarrhea and requested for an antidiarrheal medication. When RN 1 was asked if Resident 1 had diarrhea (loose, watery stools) before she stated, "No." On February 17, 2012, a review of a nurse's note written by RN 1 on February 17, 2012, and timed at 12 noon, indicated Resident 1 complained of diarrhea and was given lomotil an anti-diarrheal medication.On February 17, 2012, a review of Resident 1's clinical record (Face sheet) indicated the resident was admitted to the facility on June 10, 2011. The resident's diagnoses included diabetes (high blood sugar), hypertension (high blood pressure), and end stage renal disease (ESRD/failure of the kidney to function) requiring hemodialysis (a machine used to remove waste products from the blood), which causes electrolyte (vital elements like potassium, calcium, sodium, and magnesium that is important for the cells in the body to function) imbalances. Consuming undercooked, non-pasteurized, eggs over-easy had the potential to put the resident at further risk of electrolyte imbalance due to diarrhea.According to the National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC), ?The kidneys control the amount of electrolytes in the body. When the kidneys fail, electrolytes get out of balance, causing potentially serious health problems. In addition, diarrhea of any duration may cause dehydration and further cause electrolyte imbalance.? The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated October 24, 2011, indicated the resident was usually able to make himself understood and understands other. According to the MDS, the resident required limited assistance from staff for activities of daily living (ADLs), such as transferring, bed mobility, ambulation, and toilet use. On February 17, 2012, during a review of all Resident 1's care plans indicated there was no prior care plan that the resident had a history of diarrhea until February 17, 2012. According to a short-term care plan, dated February 17, 2012, the resident had a problem with loose soft bowel movement after a meal. The goal for the resident was to have no loose bowel movements after meals for one week. In addition, the staff were to monitor the resident's food intake and frequency of stools.According to the United States Department of Agriculture (USDA) on Food Safety education, "Salmonella is caused by undercooked eggs and can cause diarrhea, fever, and abdominal cramps. In people with weakened immune system, the infection may be more severe and lead to serious complications, including death." A review of the facility's undated Meal Service and Tray Assembly policy, indicated no items should be placed on trays sooner than 30 minutes prior to tray service. Acceptable food temperatures and quality must be maintained. The policy also indicated cold beverages should be held in the refrigerator or freezer or placed in an iced down bin before being placed on trays to maintain a safe temperature and the temperature should be at 41 degrees F or less when leaving the kitchen. In another review of the facility's undated policy, titled, "Sanitation and Infection Control in Preventing Blood Borne Illness," indicated hot foods needs to be kept hot (above 140 degrees Fahrenheit) and cold foods be kept cold (below 41 degrees Fahrenheit). The policy also indicated the most common food borne disease cause by uncooked eggs and diary products are Salmonella. Symptoms of Salmonella infection included headache, vomiting, fever, stomach pain, intestinal pain, and diarrhea.According to the Center for Disease Control and Prevention (CDC) report for 1993 ? 1997, ?Surveillance for Food-borne Disease Outbreaks ? United States,? identified the most significant factors to food borne illness. Improper cooking and improper holding temperatures are two of several categories identified as contributing factors directly relate to food safety concerns. b. On February 17, 2012, the surveyors were accompanied by the cook to inspect the food storage room, which was located outside in a garage shed converted into a storage room. The storage room was located in the back of the building, in a non-air conditioned and non-ventilated area approximately 150 feet from the kitchen. The foods such as, the saltine crackers, pancake syrup, cheese cake mix, open box dehydrated potatoes and other canned foods were observed stored on shelves line up on the perimeter against the walls. In addition, the storage area had no windows or ventilation. According to an article titled, "Proper Storage Temperatures for USDA Commodities" dry storage area should be clean with good ventilation to control humidity and prevent growth of mold and bacteria. The food should be off the floor and away from the walls to allow for adequate air circulation. The stored dry food's room temperature should be at 50 degrees F for a maximum shelf life and it should also indicate the temperature of the storage room and be checked daily.c. On February 17, 2012 at approximately 7:10 a.m., during a tour of the food storage room the refrigerator and freezer temperature logs were observed hanging on the doors. According to the log, the last time the staff checked the temperature was December 29, 2011, which was 50 days ago. When the cook was asked what was the facility's policy about monitoring the refrigerator and freezer temperature she stated, "We are suppose to logged in the temperature of the refrigerator daily on the temperature record chart. According to the USDA on Refrigeration and Food Safety education, last updated on May 11, 2010, "A refrigerator is one of the most important pieces of equipment in the kitchen for keeping foods safe. Refrigeration slows bacterial growth and bacteria exist everywhere in nature. For safety, it is important to verify the temperatures of the refrigerator. Refrigerators should be set to maintain a temperature of 40 degrees F or below." A review of the facility's undated policy, titled, "Sanitation and Infection Control," indicated the temperature of the refrigerators should be recorded daily.d. On February 17, 2012, at approximately 6:50 a.m., one gallon of a half-full non-preservative (chemical substance used to preserve the food) salsa (tomatoes with and onions), one gallon of barbeque sauce half-full, and one gallon of soy sauce with one-third left was observed underneath the steam tray. Two of the containers were not dated when opened, but the salsa was dated opened October 2011. Review of the label of soy sauce, barbeque sauce, and salsa showed it should be refrigerated after opening for quality. When the cook was asked why these food containers were not refrigerated she stated, "I did not know the salsa, barbeque and soy sauce should be refrigerated after opening.? The surveyor showed the cook the food labeling and asked her to make a copy. During an interview, on February 17, 2012, at approximately 10:18 a.m., the RD was asked if she was aware the salsa, barbeque and soy sauce was not refrigerated she stated, "No I didn't know that, and it really should be."A review of the facility undated policy titled, "Refrigerated Storage Guidelines" indicated barbeque sauce should be refrigerated at 38 degrees F to 41 degrees F after opening.e. On February 17, 2012, at approximately 6:50 a.m., the cook was observed removing a black shopping bag with no label or date on it from the refrigerator inside the kitchen. When she was asked what was in the bag, she opened the shopping bag which contained partially frozen pork chops to be served for lunch without any covering. When the cook was asked if the pork chops were being stored in sanitary conditions she stated, ?No, and it wasn't suppose to be in that bag.?During an interview, on February 17, 2012, at approximately 10:18 a.m., the registered dietician (RD) consultant stated the pork chops should be placed in a plastic storage bag, labeled, and dated. When she was asked if using shopping bags to store food was appropriate or sanitary she stated, "No."A review of the facility's undated policy titled, "Refrigerated Storage,? indicated all refrigerated foods will be covered properly. All meats, poultry and fish placed in the refrigerator for thawing must be labeled and dated.The facility failure to: 1. Follow its policy in serving residents only pasteurized eggs. 2. Ensure residents were served food that was prepared following safe food handling procedures to ensure food safety and prevent potential for foodborne illness, which was identified for four of four residents (Resident 1, 2, 3, and 4). 3. Check all food temperature prior to serving the food trays to the residents to ensure proper and acceptable food temperature as per State?s regulation and facility?s policy. 4. Monitor food temperatures and functioning of the refrigeration equipment daily as per its policy. 5. Properly store, prepare, and serve food under sanitary conditions to ensure food safety and prevent potential for foodborne illness for residents in the facility.The above violations had a direct relationship to the health, safety, and security for Residents 1, 2, 3, 4, and all other residents in the facility. |
| 630011138 |
ST. RITA'S HAVEN 2 |
980009553 |
B |
12-Oct-12 |
8V0E11 |
12261 |
72321 (a) NURSING SERVICES ? PATIENTS WITH INFECTIOUS DISEASE Patients with infectious diseases shall not be admitted to or cared for in the facility unless the following requirements are met: Separate provisions for handling linens (72321 (a) (2)(A) 72321 (b)The facility shall adopt, observe and implement written infection control policies and procedures. These policies and procedures shall be reviewed at least annually and revised as necessary. Based on observation, interview and record review, the facility failed to prevent the spread of infection in the facility by failing to adopt and implement infection control policies and procedures; and by failing to ensure that they had separate provisions for handling linens for patients with infectious disease. On 8/30/12, at 9 a.m., a licensing visit was done for the purpose of adding three (3) additional beds to the facility?s exisitng 6 beds.According to the facility roster, there were four active patients. During the initial tour, Patient 2's room had a posted note, ?Contact Isolation, use gloves, mask and gown.? When asked what the infection was, Employee A, a licensed vocational nurse (LVN) stated that Patient 2 had MRSA (Methicillin Resistant Staphylococcus Aureus, a type of staphylococcus bacteria that is resistant to certain antibiotics ) infection of both nares.At 11 a.m., Employee C (a Nursing Assistant) entered Patient 2's room with gloves and mask, but with no gown. She proceeded to provide care such as oral care, changing clothes, and transferred the patient from bed to the wheelchair. When this was brought to the attention of Employee A, she stated staff are expected to use gowns as well. When asked why she did not wear an isolation gown, Employee C did not give any answer to the surveyor. During the tour with Employee A, all 4 patients had their own rooms with no roommates. There was no isolation gowns observed anywhere in the house. Employee A did not give an explanation why there was none.At 11:45 a.m., the survey team requested to see the facility's policy and procedure manual regarding infection control. However, Employee A was not able to show a policy and procedure manual. Instead, she provided a binder containing copies of pages from an Infection Control Book and presented a specific page regarding MRSA infection. However, the reference did not include any specific facility policies and procedures to follow in preventing the spread of infection at the facility. When requested to speak with the Administrator/DPCS, the facility owner stated she not available.Record review revealed that Patient 2 was admitted to the facility on 7/26/11, with diagnoses of acute respiratory failure (inadequate gas exchange by the respiratory system), gastrostomy tube placement (tube inserted through small incision in the abdomen into the stomach and used for long- term enteral nutrition), permanent tracheostomy (surgical procedure to create an opening through the neck into the windpipe to provide airway and to remove secretions from the lungs) and was developmentally disabled with Pierre Robin Syndrome (condition present at birth, in which the infant has a smaller than normal lower jaw, a tongue that falls back in the throat and difficulty breathing). The admission diagnoses did not include MRSA infection. Patient 2 was assessed as alert, but non- verbally responsive and required extensive assistance with his activities of daily living. The patient was admitted to the facility for bundled skilled nursing, to perform and assess safety measures including universal precautions and infection precautions. The care plan dated 3/6/12, indicated that the patient had potential for transmission of infection related to bacteria and the approaches included assessing the patient for increase or decrease in signs and symptoms of infection. On 8/30/12, at 10 a.m., Patient 2 was observed with a tracheostomy tube intact connected to a ventilator machine (a machine to aerate the patient?s lung. He had a gastrostomy tube connected to an ongoing feeding.A review of the facility?s infection control surveillance report indicated that on 8/10/12, Patient 2 was identified positive for MRSA on his nares. He was treated with Bacitracin 500 units/gram ointment applied to nares daily for 10 days, and was placed on contact isolation. Further review of the facility?s "Infection Control Surveillance" and clinical record review revealed the following information of the 3 other patients in the facility (Patient 1, 3, and 4) who also developed MRSA infection: 1. On 8/30/12, record review revealed that Patient 1 was admitted to the facility on 10/6/11, with diagnoses of acute respiratory failure (inadequate gas exchange through the respiratory system), gastrostomy tube placement (tube inserted through small incision in the abdomen into the stomach and used for long-term enteral nutrition), permanent tracheostomy (surgical procedure to create an opening through the neck into the windpipe to provide airway and to remove secretions from the lungs) and diabetes ketoacidosis uncontrolled. The admission diagnoses did not include MRSA infection. The patient was admitted to the facility for 24-hours bundled skilled nursing, to perform and assess safety measures as universal precautions and infection precautions. He was assessed as alert, verbally responsive but required extensive assistance with his activities of daily living. The care plan dated 3/6/12, indicated that the patient had potential for transmission of infection related to bacteria and the plan included assessing the patient for increase or decrease in signs and symptoms of infection. On 8/30/12, at 12:30 p.m., Patient 1 was observed sitting in his wheelchair, with a tracheostomy intact. The patient stated he also has a gastrostomy stoma which is healing slowly because he has infection. A review of the nurses? notes dated 8/20/12, revealed Patient 1 developed MRSA of the gastrostomy stoma site and was placed on contact isolation on 8/21/12. The MAR (Medication Administration Record) indicated he was given Doxycycline 100 mg. (milligrams) twice a day for 10 days (8/21/12-8/30/12. A review of the facility?s infection control surveillance report indicated Patient 1?s MRSA was identified on 8/1/12.On 8/30/12, there was no precaution sign outside of the patient?s door and there was no set up for gloves, masks or gown.2. On 8/30/12, record review revealed that Patient 3 was admitted to the facility on 10/21/11, with diagnoses of acute respiratory failure, gastrostomy tube placement, permanent tracheostomy, and hypertension. The admission diagnoses did not include MRSA infection.The patient was admitted to the facility under the Adult sub-acute NF-AH waiver for 24 hours bundled skilled nursing to perform and assess safety measures as universal precautions and infection precautions. She was assessed as alert and respond in signed language, but required extensive assistance with his activities of daily living. During the initial tour, Patient 3 was observed sitting in a wheelchair. Her tracheostomy was intact and gastrostomy tube feeding was ongoing. She was alert and able to communicate with sign gestures. The care plan indicated that he had a potential for transmission of infection related to bacteria and the approaches included to assess resident for increase or decrease in signs and symptoms of infection. A review of patient?s laboratory report dated 8/8/12, revealed she was identified with MRSA infection of the tracheostomy site, and was placed on contact isolation. The MAR indicated she was given Gentamycin 80 mg intramuscularly three times a day for 7days (8/13/12 ? 8/20/12). However, a review of the facility?s infection control surveillance report indicated the onset of Patient 3?s MRSA on the tracheotomy site was 8/16/12, and was placed on isolation.There was no precaution sign outside of the patient?s door and there was no set up for gloves, masks or gown. 3. On 8/30/12, record review revealed that Patient 4 was admitted to the facility on 3/1/11, with diagnoses of acute respiratory failure, craniotomy, ( a bone flap is temporarily removed from the skull to access the brain); and craniectomy (surgical removal of a portion of the cranium), gastrostomy, and tracheostomy, and obstructive hydrocephalus ( passage of cerebrospinal fluid is blocked). The admission diagnoses did not include MRSA infection. The patient was admitted to the facility under the adult sub-acute NF-AH waiver for 24 hours bundled skilled nursing, to perform and assess safety measures as universal precautions and infection precautions. She was comatose and required extensive assistance with his activities of daily living. The care plan dated 2/15/12 indicated the patient had potential for transmission of infection related to bacteria.The facility?s infection control surveillance report indicated the onset of Patient 4?s MRSA of the urine was 8/7/12, and was placed on contact isolation. Further review of Patient 4?s clinical record revealed that on 8/21/12, there was a telephone order for Macrobid 100 mg per gastrostomy tube twice a day for 7 days and Amikacin 250 mg. intramascularly twice a day.There was no precaution sign outside of the patient?s door and there was no set up for gloves, masks or gown. At 12:30 p.m., during another tour of the facility, the clothes washer and dryer were observed in the kitchen beside the refrigerator. When asked how staff handled soiled linens, the owner stated patients? clothing are washed separatelyin the facility washer, and linens are picked up by the linen/laundry contractor. When asked about the policy and procedure of how to handle linens and clothing from the infected patients, she was not able to provide the requested material. When asked about a contract with the linen company, she provided receipts, but not a contract. At 3 p.m., when requested to speak with the Administrator/DPCS again, the facility owner stated she was on her way. However, she never showed up during the first day of survey. On 8/31/12, at 2 p.m., all the patients? rooms have precaution signs to wear masks, gloves and gown. They all had masks, gloves and gown outside of the door. When asked why there was no isolation gowns during the first day, Employee A stated there was no place to store them. The survey team again requested the facility?s policy and procedure for infection control including handling of linens/clothing. Employee A and the owner of the facility stated that the infection control manual was at another facility and they were unable to provide to the survey team. When requested to provide evidence that the staff were trained on how to care for patients with infection, they were not able to show any evidence. On 8/31/12, at around 5:30 p.m., when the above findings were discussed, the Administrator/DPCS was not able to provide any additional information or documents. The Center for Disease Control and Prevention recommendations include the following: 1. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin. 2. Use masks to protect the mucous membranes of the nose and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions.3. Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated. 4. Handle, transport, and process used linen to avoid contamination of air, surfaces and persons.The facility failed to ensure that patients with infectious diseases were not cared for in the facility unless there were separate provisions for handling linens. The facility failed to adopt, observe and implement written infection control policies and procedures. The above violations had a direct relationship to the health and safety of the patients, staff, and visitors at the facility. |
| 630010951 |
ST. RITA'S HAVEN |
980009579 |
B |
02-Nov-12 |
None |
10020 |
Class B Citation- Patient Rights Title 22 Section 72527 Written policies regarding the rights of patients shall be established and shall be available to the patient, to any guardian, next of kin sponsoring agency or representative payee and to the public. Such policies and procedures shall ensure that each patient admitted to the facility shall have the following rights and be notified of the facility?s obligations. 72527 (a) (8) To be free from mental and physical abuse and to be free from chemical and (except in emergencies) physical restraints except as authorize in writing by a physician or other person lawfully authorized to prescribe care for a specified and limited period of time when necessary to protect the patient from injury to himself or to others. 72527 (a) (10) To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs.On August 30, 2012, an unannounced visit was made to the facility to investigate a complaint regarding allegations of patient abuse. Based on interviews and record reviews, the facility failed to: 1. Establish 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. 2. Ensure Patient A was free from mental abuse. 3. Ensure Patient A was treated with consideration, respect, full recognition of dignity and individuality. On 8/30/12, at 12:12 p.m., a review of Patient A?s record revealed a 36 year old female who was admitted to the Congregate Living Health Facility (CHLF) (residential home that provides 24-hour skilled nursing) on 11/29/11, with diagnoses that included acute respiratory failure, ventilator (equipment to move air in and out of the lungs) dependent, chronic obstructive airway, tracheostomy (airway opening to remove secretions from the lungs). Patient A required assistance from the facility for all her activities of daily living (bathing, dressing, oral hygiene, toileting etc.). The plan of care for the certification period of 3/28/12 to 5/27/12 indicated the patient was oriented and able to make her needs known to the staff.On 8/30/12, at 9:13 a.m., during an interview, Family Member 1 stated she was notified by the hospital staff on 5/7/12, that Patient A was transferred from the CLHF to the acute care hospital for being suicidal. She stated that when she spoke to Patient A, she was crying, stating that she had an argument with the DON over who is going to bathe her. She thought the DON called 911 just to have her removed from the facility. On 8/30/12, at 9:49 a.m., during an interview, Patient A stated that CNA1 was her usual caregiver. On 5/7/12, CNA1 was on duty, but LVN1 (a new male licensed vocational nurse), informed her he would be bathing her. Patient A stated when LVN 1 prepared to bathe her, she was uncomfortable with the way LVN1 stared at her private parts. She stated she told the Director of Nurses (DON) that she was not comfortable with the way LVN 1 stared at her private parts, so she did not want him bathing her, and requested CNA1 to bath her. Patient A stated the DON told her that she did not have any rights to choose who would bathe her and insisted that LVN1 was going to give her a bath. Patient A stated she and the DON started arguing with each other, and the next thing she knew, the DON walked out of the room saying, ?I know how to take care of this situation?. Patient A stated CNA1 then came in the room to bathe her. Patient A stated that right after her bath, while in bed watching television, two paramedics came in and told her they were taking her to the hospital. Patient A stated she was not sick, so she thought the DON was sending her to a psychiatric ward, because she and other patients in the facility had been threatened at least weekly, that if they complained or caused any problems with the staff, they would be sent to a psychiatric ward. Patient A stated that when she was at the emergency department (ED) of the hospital, staff told her that the facility informed the paramedics and hospital staff that she was suicidal. She denied being suicidal. Patient A stated she was upset by the way she was treated by the DON. Just thinking about what happened made her cry. She remained in the hospital for about a week from 8/5/12 to 8/15/12, until the hospital was able to find another facility to place her, because she did not want to return to the CLHF.O 8/30/12, at 10:10 a.m., during an interview, Hospital Staff 1 stated that based on her evaluation of Patient A on 5/8/12, she determined the patient was not suicidal and indicated a possible abuse issue by the CLHF staff. Patient A was crying throughout her evaluation and told her that she did not want to stay at the CLHF any longer.Hospital Staff 1 stated she called the CLHF after her evaluation, questioning why Patient A was sent to the hospital and she did not get any information. She informed the CLHF of her evaluation that the patient was not suicidal. She further stated that the patient was depressed over how she was treated at the CLHF with the thought the facility sent her to the acute hospital just to get rid of her. The patient had to be started on Celexa (a medication used to treat depression).A review of the CLHF Nursing Progress Notes dated 5/7/12 revealed Patient A went to the acute hospital at 12 noon. There was nothing documented or communicated about Patient A?s behavior and condition during transfer to the acute hospital.On 8/30/12, at 4:30 p.m., a review of the ED nursing summary history dated 5/7/12, revealed Patient A was admitted to the acute hospital from the CLHF. According to the CLHF the patient was refusing to eat, take her medications, and had possible suicidal ideations. Upon arrival to the ED the patient was tearful stating she is not suicidal. She stated she complained about LVN 1 inappropriately looking at her private parts. She felt uncomfortable, so she insisted on having CNA1 give her a bath instead. The nursing summary history indicated that according to paramedics, the CLHF staff told them that Patient A needed to go to the emergency room because she was suicidal.Review of the hospital History and Physical examination dated 5/7/12, revealedthat Patient A was brought in by ambulance to the acute hospital for alleged suicidal ideation. Upon arrival to the ED, the patient was tearful and stated that she is not suicidal. She stated she just had an argument with the DON because LVN 1 was looking at her private parts and that made her very uncomfortable.Review of the hospital?s Medical Psychological Consultation dated 5/8/12, at 11:30 a.m., revealed the patient was very tearful during the history and physical examination. The patient denied suicidal ideation. She said that she got into an argument with the DON, who was yelling at her. She stated when she complained about LVN 1looking into her private areas, the DON got very upset and transferred her to the hospital. The patient does not want to go back to the CLHF when she is discharged from the acute hospital. She ultimately wants to go home, and her mother will take care of her, when she knows more about the respiratory status.? The diagnosis included adjustment disorder with mixed emotional features of anxiety and depression but is under control. The treatment recommendations were supportive therapy in order to provide the patient with the opportunity to discuss emotional, cognitive, affective and psychosocial aspects of the patient?s diagnosis. A review of the hospital discharge summary dated 5/15/12, indicated, the patient was brought in via ambulance to acute hospital for the alleged suicidal ideation. Upon arrival to the ED, the patient was tearful and stated that she is not suicidal, had an argument with the staff and the DON at the sub-acute facility. Apparently, a male LVN was looking at her private area but there was no inappropriate touching. This made the patient uncomfortable and she got into an argument with the DON, who called the paramedics informing them that the patient is suicidal. The patient denies any suicidal or homicidal ideation. The patient is refusing to go back to the same facility that she came from. The discharge summary indicated that the patient was never suicidal or homicidal throughout her hospitalization.On 8/30/12, the DON was not available. Several requests were made for Staff 1 and Staff 2 to provide for review the policy and procedures on patient rights, admission, transfer, and discharge, at 10:30 a.m. and at 11:28 a.m. They were unable to provide the policies and procedures (P&P). During a telephone interview with the DON, on 8/30/12, at 11:30 a.m., she was informed of the need to review the P&P. She stated Staff 1 and Staff 2 should be able to provide it to the surveyors. However, at 2:30 p.m., Staff 1 and 2 still were not able to provide any P&P to review. Staff 1 stated the DON is revising the P&P at home.On 8/31/12, at around 5:30 p.m., when the above findings were discussed, The DON was not able to provide any additional information. LVN 1 and CNA1 were not made available for interview. A telephone call was made at 2:45 p.m. on 8/30/12, and on 8/31/12 to LVN1 and CNA1. There was no answer. A message was left requesting a return call. There was no return call.The facility failed to: 1. Ensure Patient A was free from mental abuse. 2. To establish 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. 3. Ensure Patient A was treated with consideration, respect, full recognition of dignity and individuality.These violations had a direct relationship to the health, safety, and security of Patient A. |
| 630013454 |
Sorrento in the Desert |
980012261 |
B |
24-May-16 |
ZWQP11 |
8193 |
HSC 1250(i)(2)C HSC Section 1250 Services for persons who are catastrophically and severely disabled. A catastrophically and severely disabled person means a person whose origin of disability was acquired through trauma or nondegenerative neurologic illness, for whom it has been determined that active rehabilitation would be beneficial and to whom these services are being provided. Services offered by a congregate living health facility to a catastrophically disabled person shall include, but not be limited to, speech, physical, and occupational therapy.On April 7, 2016 at 3:15 p.m., an unannounced visit was made to the facility to investigate complaint allegations regarding quality of care/resident safety due to multiple transfers to general acute care hospitals (GACH). Based on observation, interview, and record review, the facility failed to ensure three of three patients (Patients 1, 2, and 3) were admitted based on the type of patient group (Type "C") the facility was licensed to provide services to. The facility's license indicated the facility was approved for Type "C" patient group, which are persons who are severely disabled and for whom it has been determined that active rehabilitation would be beneficial and to whom these services are being provided. The facility admitted Patients 1, 2 and 3, who were dependent on ventilators (machines used in artificial respiration to control or assist in breathing) and in vegetative states (absence of responsiveness and awareness due to overwhelming dysfunction of the brain) and did not meet the Type "C" patient group. This deficient practice had the potential for the patients to not receive appropriate care and services.During a tour of the facility on April 7, 2016 at 3:30 p.m., with Director of Nursing 1 (DON 1), Patients 1, 2, 3 were observed lying in their beds and connected to ventilators. According to DON 1, the three patients were bedridden and totally dependent on staff assistance for all their activities of daily living. When greeted, Patients 1, 2, and 3 did not respond to verbal stimuli. A review of the facility's license, which was hung on the wall, indicated the facility was approved for Type "C" patient group. Type "C" patient group is described in the Health and Safety Code 1250 (i) (2) (C) as services for persons who are catastrophically and severely disabled. A catastrophically and severely disabled person means origin of disability was acquired through trauma or non-degenerative neurological illness, for whom it has been determined that active rehabilitation would be beneficial and to whom these services are being provided. Services offered by a congregate living health facility to a catastrophically disabled person shall include, but not be limited to, speech, physical, and occupational therapy.a. A review of Patient 3's Admission and Discharge Summary indicated the patient was originally admitted to the facility on March 28, 2014, with diagnoses including respiratory failure (a condition in which not enough oxygen passes from the lungs to the blood), tracheostomy (incision in the windpipe to aid breathing), and dysphagia (difficulty swallowing).Patient 3 was on a waiver program for home and community-based services. The In Home Operation Section, Home and Community-Based Services, Manual Plan of Treatment (POT), treatment period from November 23, 2015 to May 21, 2016, indicated Patient 3's diagnoses included history of anoxic encephalopathy (loss of oxygen to the brain and loss of brain function) following cardiopulmonary arrest, ventilator dependence, and gastrostomy tube ((feeding tube inserted directly into the stomach). Patient 3 was in vegetative state, opened his eyes, and did not follow commands. Patient 3 required total assistance with his activities of daily living. There was no documentation in the medical record to indicate Patient 3 was receiving speech, physical, or occupational therapy. The facility transportation log indicated Patient 3 was transferred to a GACH on the following dates: April 1, 2014 due to respiratory distress; July 11, 2014 due to evaluation; September 1, 2014 due to elevated blood pressure; January 11, 2015 due to decreased oxygen saturation level; June 22, 2015 due to Clostridium Difficile (bacterial infection of the colon); October 21, 2015 due to respiratory distress; November 7, 2015 due to blood in urine; November 24, 2015 due to (unknown); November 28, 2015 due to infection; December 30, 2015 due to blood in urine; February 14, 2016 due to respiratory distress; February 27, 2016 due to shortness of breath; b. A review of Patient 2's Admission and Discharge Summary indicated the patient was originally admitted to the facility on April 11, 2015, with diagnoses including ventilator dependence and gastrostomy tube.Patient 2 was on a waiver program for home and community-based services. The In Home Operation Section, Home and Community-Based Services, Manual Plan of Treatment (POT), treatment period from January 3, 2016 to June 30, 2016, indicated the diagnoses included respiratory failure, anoxic brain damage (condition in which there is decrease of oxygen supply to the brain), and vegetative state. Patient 2 required total assistance with bathing, eating, and dressing. There was no documentation in the medical record to indicate Patient 2 was receiving speech, physical, or occupational therapy. The facility transportation log indicated Patient 2 was transferred to a GACH on the following dates: May 30, 2015 due to clogged feeding tube; December 16, 2015 due to ventilator malfunction; December 27, 2015 due to blood in her tracheostomy; February 22, 2016 due to feeding tube replacement; c. A review of Patient 1's Admission and Discharge Summary indicated the patient was originally admitted to the facility on March 25, 2015, with diagnoses including traumatic brain injury from a motor vehicle accident, ventilator dependent, vegetative state, and gastroscopy.Patient 1 was on a waiver program for home and community-based services. The In Home Operation Section, Home and Community-Based Services, Manual Plan of Treatment (POT), treatment period from December 20, 2015 to June 6, 2016, indicated Patient 1 was admitted to the facility in a persistent vegetate state, unable to move all extremities and required maximum assistance in transferring, mobility, toileting, dressing, and bathing. There was no documentation in Patient 1's medical record to indicate he was receiving speech, physical, or occupational therapy. A review of a facility transportation log indicated Patient 1 was transferred to a GACH on the following dates: March 25, 2015 due to high blood pressure; August 16, 2015 due to low oxygen saturation (amount of oxygenated hemoglobin (red blood cells) in the blood. February 9, 2016 due to coffee ground emesis; During an interview on April 7, 2016 at 5 p.m., DON 1 stated she had been working at the facility for about 2 weeks and was not familiar with the licensing requirements and left that up to the owner of the facility.During several interviews with the owner of the facility between 5 p.m. and 8 p.m. on April 7, 2016, she repeatedly stated it was appropriate to have admitted the three ventilator dependent patients into her facility even though the facility's license indicated otherwise. The facility's undated policy and procedure titled, "Client Screening and Admission Process," indicated prospective clients are screened for admission in accordance with CLHF (Congregate Living Healthcare Facility) regulations and the facility's policy and philosophy. The President or a designee is the primary facilitator for communication and assistance in this process. The President evaluates and interviews prospective clients and significant others for admission, facilitates the final evaluation and determination of acceptance into the facility, and arranges for the client to be assessed by the Registered Dietician, Licensed Clinical Social Worker, and Recreation/Rehabilitation Consultant after admission. This violation had a direct relationship to the health and safety of Patients 1, 2, and 3. |
| 630013454 |
Sorrento in the Desert |
980012648 |
B |
21-Oct-16 |
8ZJW11 |
9072 |
T22 DIV5 CH3 ART5-72523(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. On 7/22/16, at 12:40 p.m., an unannounced visit was made to the facility to investigate a complaint regarding the discharge of Patient 1. The patient was discharged home and her caregiver (family member) was not trained to care for the patient. The patient was transferred to the general acute care hospital for respiratory distress. Based on record review and interview, the facility failed to implement its written patient care policies and procedures regarding discharge for Patient 1. For Patient 1, who had diagnoses including tracheostomy (surgical opening through the neck into the airway to relieve obstructions to breathing) and gastrostomy tube (feeding tube that is inserted into the stomach and used to supply nutrition), the facility failed to provide a discharge orientation and a post-discharge plan prior to Patient 1 being discharged home. As a result, when the home health nurse visited Patient 1 at home, she found Patient 1 was having breathing difficulty and Patient 1?s family member was not trained on how care for the patient?s tube feeding and tracheostomy. The home health nurse called 911 (medical emergency telephone number) and Patient 1 was transferred to a general acute care hospital. A review of the admission face sheet indicated Patient 1 was admitted to the facility on 2/4/14 with diagnoses including respiratory failure (inadequate gas exchange by the respiratory system and oxygen and carbon dioxide cannot be kept at normal levels), tracheostomy, gastrostomy tube (feeding tube), kidney failure, and head trauma. A review of a Daily Skilled Nurse's Note dated 7/19/16, indicated the following: At 9:50 a.m., Patient 1 was bathed, dressed, and ready to be picked up by the ambulance. According to the note, at 11:30 a.m., the ambulance arrived at the facility to transport the patient, but the patient was not released for discharge because the family member was not present and the patient's equipment was not set-up at home. At 11:50 a.m., the patient's family member arrived at the facility and along with other family members and friends, they helped pack up all Patient 1's belongings, hospital bed and equipment. They took Patient 1?s belongings and a facility staff instructed the family to call the facility after the bed and equipment were set-up. At 3:30 p.m., the patient was transferred home via ambulance. A review of another Daily Skilled Nurse's Note dated 7/19/16, written in narrative style and untimed, indicated that upon discharge, Patient 1's family member called the facility several times with questions from the home health nurse about setting up the feeding pump. Then, the home health nurse called the facility and stated she did not want to leave the feeding pump running because she did not feel the family member could safely operate it. According to the note, when the facility staff member asked the home health nurse if she would stay with the patient, the home health nurse stated the home health agency would not be able to provide continuous, around the clock nursing care to Patient 1. A review of Patient 1?s medical record indicated there was no post-discharge plan developed, no discharge orientation completed and reviewed with the patient?s family member before Patient 1 was discharged from the facility. During an interview with Skilled Nurse (SN) 1 on 7/22/16 at 12:45 p.m., she stated Patient 1's family member wanted to bring the patient home for a long time. SN 1 stated the patient had a tracheostomy, needed to be suctioned frequently and had breathing treatments every six hours. SN 1 stated the patient was incontinent of bowel and bladder and required two person assist with all her activities of daily living, including personal hygiene, transferring, and positioning. SN 1 stated Patient 1's family member had never assisted with the patient's care when she visited the facility and had not been trained to provide care to the patient. During an interview with SN 2 on 7/22/16 at 1 p.m., she stated Patient 1 had very thick secretions, required frequent suctioning, and received medications and breathing treatments throughout the day. SN 2 stated the patient required 24 hour care and assumed the home health agency would provide around the clock nursing care and would provide teaching for the caregiver (family member). She stated the family member was not at the facility often enough to provide her with training. SN 2 stated the facility staff did not provide transfer/discharge orientation to the caregiver. She stated, "If we had provided an interdisciplinary team meeting, I would not have discharged the patient. We thought the home health agency was providing 24 hour care and that they would do the teaching." During an interview with the case manager from the home health agency on 7/28/16 at 2 p.m., she stated the family member had called the agency and told them the patient was at home. She stated the agency was not providing 24 hour care. When the agency's home health nurse found the caregiver was not trained on how to care of the patient?s feeding tube and tracheostomy, and the patient was having difficulty breathing, the home health nurse called 911 (medical emergency telephone number). A review of the Communication Note from the home health agency?s visiting nurse, dated 7/19/16, indicated Patient 1 arrived home at 4:30 p.m. and home health nurse arrived for the initial assessment at 5:00 p.m. The visiting nurse assessed Patient 1?s respirations were very labored, the patient was using oxygen, had thick yellow secretions, and the patient was having breathing difficulty. The caregiver stated she had not been trained to take care of the patient?s tracheostomy and feeding tube, and expected the home health agency would provide 24 hour nursing care for the patient. The visiting nurse felt the patient was unsafe at home and called 911 for the emergency transfer to the general acute care hospital. The facility's policy and procedure titled, "Transfer or Discharge Orientation," revised April 2013, indicated the facility shall prepare a resident for a transfer or discharge. When a resident is scheduled for transfer or discharge, the business office would notify nursing services of the transfer or discharge so that appropriate orientation procedures could be implemented. A post-discharge plan is developed for each resident prior to his/her transfer or discharge. This plan would be reviewed with the resident, and/or his/her family, at least 24 hours before the resident's transfer or discharge from the facility. The purpose of the orientation is to provide the resident and family with sufficient preparation and to ensure a safe and orderly transfer or discharge from the facility. The facility's policy and procedure titled ,"Transfer or Discharge, Preparing a Resident for," revised April 2014, indicated the facility shall prepare a resident for transfer or discharge and Nursing Services would be responsible for preparing the discharge summary and post-discharge plan. The facility's policy and procedure titled, "Discharge Summary and Plan," revised April 2013, indicated when the facility anticipates a resident's discharge to a private residence, a post-discharge plan would be developed which would assist the resident to adjust to his or her new living environment. The post-discharge plan would be developed by the Care Planning/Interdisciplinary Team with the assistance of the resident and family and would contain as a minimum: A description of the resident's and family's preferences for care; A description of how the resident and family will access such services; A description of how the care should be coordinated if continuing treatment involves multiple caregivers; The identity of specific resident needs after discharge (i.e., personal care, sterile dressings, physical therapy, etc); and A description of how the resident and family need to prepare for the discharge. The Social Services Department will review the plan with the resident and family 24 hours before the discharge is to take place. The facility failed to implement its written patient care policies and procedures regarding discharge for Patient 1. For Patient 1, who had diagnoses including tracheostomy and gastrostomy tube, the facility failed to provide a discharge orientation and a post-discharge plan prior to Patient 1 being discharged home. As a result, when the home health nurse visited Patient 1 at home, she found Patient 1 having breathing difficulty and Patient 1?s family member was not trained on how care for the patient?s tube feeding and tracheostomy. The home health nurse called 911 and Patient 1 was transferred to a general acute care hospital. This violation had a direct relationship to the health and safety of Patient 1. |
| 630010951 |
ST. RITA'S HAVEN |
980012780 |
B |
29-Nov-16 |
KPYP11 |
4335 |
1418.91(a) Health & Safety 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. 1418.91(b) Health & Safety 1418 (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 9/22/16, at 1 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient 1 was being physically abused by License Vocational Nurse (LVN) 1. Based on record review, observation, and interview, the facility failed to report an incident of an alleged abuse of a patient of the facility by failing to report to the Department immediately, or within 24 hours an allegation that LVN 1 hit Patient 1 him on the chest while suctioning from the patient?s tracheostomy tube. A review of the Admission Physician Orders indicated Patient 1 was admitted to the facility on 1/11/16, with diagnoses that included respiratory failure (inadequate gas exchange by the respiratory system, meaning that the arterial oxygen, carbon dioxide or both could not be kept at normal levels), status post tracheostomy (surgical opening through the neck into the airway to relieve obstruction to breathing), and incomplete quadriplegia (paralysis caused by injury or illness that results to incomplete loss of use of arms, chest and legs). A review of the Police Department Investigative Report indicated the police responded to a radio call. The call alleged Patient 1 was physically abused at the facility, the family member reported that a staff was mean to the patient and one of the staff members had hit him, and the family member wanted to take the patient home. On 9/22/16, at 1:30 p.m., Patient 1 was observed lying in the bed, in a supine position, with the head of the bed was elevated at 30 degree angle. The patient had a tracheostomy connected to a ventilator machine. On 9/22/16, at 2 p.m., during an interview, Patient 1 denied the allegation that LVN 1 hit him. On 9/22/16 at 2:30 p.m., an interview was conducted with the director of nurses (DON). The DON stated that on 9/20/16, at 4 p.m., Patient 1's family member was at the facility. The DON stated the family member had told the administrator that LVN 1 hit the patient on the chest and he was not treated well. The DON stated that LVN 1 did not hit the patient, but LVN 1 cupped his hands and tapped the patient's chest to loosen the phlegm while he suctioned from the patient's tracheostomy tube. On 9/22/16 at 3 p.m., during an interview, LVN 1 stated that he never hit Patient 1. LVN 1 stated he suctioned the patient several times on his shift. LVN stated he did a procedure called "cupping" on his chest to loosen the phlegm while suctioning from the patient's tracheostomy tube. On 9/22/16 at 3:30 p.m., an interview was conducted with the administrator. The administrator stated that Patient 1's family members were at the facility on 9/20/16, at 4 p.m. The family members were creating disturbance, refusing to leave, shouting and bothering other patients so he called the police. The administrator also stated Patient 1's family member complained that LVN 1 was physically abusing him by hitting him on the chest. He also stated that the facility had an investigation report, suspended LVN 1 until they concluded their investigation. However, the administrator stated that he did not report the alleged abuse to the Department. A review of the facility's Resident/Accident/Incident Report dated 9/20/16 and Investigative Follow-Up dated 9/21/16 indicated there was no documentation that the alleged incident of abuse was reported to the Department. A review of the facility's undated policy and procedure titled, "Elderly Abuse and Neglect," indicated anyone who knows of an elderly person being abused or neglected is obligated to notify the proper authorities. The facility failed to report an incident of an alleged abuse of a patient of the facility by failing to report to the Department immediately, or within 24 hours, an allegation that LVN 1 hit Patient 1 him on the chest while suctioning from the patient's tracheostomy tube. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1. |
| 630013966 |
Stonebridge Manor |
980012797 |
B |
7-Dec-16 |
U4UL11 |
5624 |
Title 22 DIV5 CH3 ART3- 72345(a) (a) All kitchens and kitchen areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. Title 22 DIV5 CH3 ART6-72637(f) General Maintenance (f) The facility shall be maintained free from vermin and rodents through operation of a pest control program. The pest control program shall be conducted in the main patient buildings, all outbuildings on the property and all grounds. An unannounced visit was made to the facility on 8/6/16 to investigate a complaint regarding rat and insect infestation. Based on observation, interview, and record review, the facility failed to keep the kitchen area protected from rodents and rat droppings, and failed to maintain its property and grounds free from rodents through operation of a pest control program. These deficient practices resulted in the potential for rats and mice to transmit diseases among the patients and employees. During the initial tour of the facility and grounds on 8/6/16 at 1 p.m., the following was observed: 1. A large hole was observed in the back yard measuring approximately 1 foot X 1 foot with exposed water pipes inside. 2. There were 4-5 vermin traps scattered around the back yard and property. 3. A large metal trap was seen on the floor in the kitchen. 4. A rolled up towel with brownish stains was observed on the kitchen floor, between the refrigerator and the cabinet. Picture #8 showed the rolled up towel had rodent droppings, black in color and shaped like large grains of rice. During an interview with Staff 1 at 1 p.m., on 8/6/16, she stated about a month ago she opened the cabinet above the stove and saw a huge rat inside. Staff 1 stated she had been working at the facility for about 6 months and had seen rats all over the facility. Staff 1 stated she had heard and seen rats on the roof and coming out of the hole in the ground in the backyard. Staff 1 stated the rats were crawling all over the trash bins and 1 week ago, the night shift nurse told her to stay out of the kitchen because of the rats and mice. Staff 1 further stated that the pest control contractor only sprayed for ants and spiders during his visits and does not do anything about the rats and mice. During an observation on 8/6/16, at 1:15 p.m., there was a large rat trap surrounded by rat droppings inside a kitchen cabinet. There were large and small wads of steel wool in the cabinet, which housed the exhaust duct over the stove which reached all the way up to the roof and was a potential entry point for the vermin. There was chipped, peeling paint and sawdust/wood chips inside the cabinet, which indicated gnawing/scratching by the rodents. This cabinet was located directly above the stove cooktop where the patients' meals were prepared (see Pictures #1, 2, and 3). During an interview with Staff 2 at that time, on 8/6/16, she stated there were dead mice in the metal trap in the kitchen (see Picture # 7), and the owner told her he was waiting to catch some more before he emptied the trap. During an interview with the Owner/Administrator on 8/6/16 at 4:10 p.m., he stated, "We have a contract with a pest control company. Sometimes (rats) come from our neighbor's property. We have a problem." The Owner/Administrator stated he told the pest control company what he was doing about the problem (putting poison in the attic and plugging holes with steel wool) and they said that was what they would do. During an interview with Pest Control 1 (representative of the pest control company) on 8/15/16 at 11:30 a.m., she stated, "They (the facility) never called us about rodents. Usually we receive calls and we go out. We inspect the property and tell them what needs to be done to seal the entrance areas and they usually don't want to pay the fee, so they do it themselves. We tell them to fill holes and seal openings where rodents get in." A review of the pest control company's invoices from 2/05/15 to 8/04/16 indicated service was provided for ants/spiders/roaches. The company came to the facility every other month during that period and sprayed the inside of the facility. No service for rats/rodents was provided. An untitled, undated policy and procedure was received from the facility on 8/12/16. The policy indicated: "In the event of any employee, contractor, patient, or any visitors will observe any rodents or pests inside of the facility or outside of the facility will report to the management of the Stonebridge Manor by calling using provided number, texting to the provided number and leaving note in the mail box of the manager of Stonebridge Manor. Any manager of (the facility) that is responsible for maintaining the facility in proper condition according to all safety codes will call contracted pest control company and request an additional visit by operator of such company (the policy did not indicate what the "additional visit" would be for). According to the Centers for Disease Control and Prevention, rats and mice can transmit diseases to humans directly through handling, contact with rodent feces and urine, and rodent bites, and indirectly through ticks, mites, and fleas that have fed on infected rodents. The U.S. Environmental Protection Agency has identified observation of rodent droppings in drawers or cupboards, and holes or signs of chewing/scratching through walls and floors as signs of rat or mouse infestation. The above violations had a direct or immediate relationship to the health, safety or security of the patients in the facility. |
| 910000075 |
SANTA MONICA CONVALESCENT CENTER I |
910013404 |
A |
19-Oct-17 |
R4P411 |
13407 |
483.25 Quality of care (F309)
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:
483.20 Resident Assessment (F281)
(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
The facility failed to provide care and services and provide care which meets professional standards by failing to:
1. Provide cardiopulmonary Resuscitation (CPR) for Resident 1, who was a full code in accordance to the Physician?s Order for life- sustaining Treatment (POLST).
2. Follow the facility's policy and procedure titled "Emergency Procedure- Cardiopulmonary Resuscitation"
3. Follow the American Heart Association Guidelines for Adult Basic Life Support for Healthcare providers.
On 6/7/2017 at 11:40 a. m., an unannounced visit was made to the facility to investigate an Entity Reported Incident involving Resident 1 who was found on 5/26/17, at around 7 a.m., unresponsive in the room, lying on the floor. The resident was found on her right side next to the corner of the night stand, lying in a pool of blood oozing from her head. The resident was pronounced dead by the emergency response team (EMS) upon arrival on the same day at 7:20 a.m. The Director of Nursing (DON) and the assistant Administrator were advised of the visit.
At 11: 55 a. m. on the same date, the DON stated she received a text message on her phone sent by Licensed Vocational Nurse 1(LVN) noting the facility had an emergency. The DON stated she arrived at the facility at 7:35 a.m and met two police officers questioning CNA 1 regarding the resident's cause of death. The DON stated she saw the resident laying on the floor unresponsive, in a lot of blood oozing from her head. The DON stated the resident looked bluish, cold and stiff. DON stated the Coroner?s Office was informed by the Police Department. The DON stated the resident's right bedside rail was down and the resident might have dropped from the bed to the floor in her sleep. The DON stated CPR was not initiated by the staff, but 911 was called. When questioned if the facility's staff had been trained on CPR, the DON stated "Yes." The DON was asked if staffs were aware of the resident's full code status to which she responded "Yes" and stated staffs are not to touch any resident on the floor, instead, they had to leave and get help from other licensed staffs.
According to the admission record, Resident 1 was an 89 year old female, who was admitted to the facility on 11/18/14. The resident had diagnoses which included dementia (a decline in mental ability severe enough to interfere with daily life).
A review of the Minimum Data Set (MDS- standardized assessment and care screening tool) dated 02/25/17, indicated Resident 1 had decreased ability to make her self-understood and to understand others. Resident 1 had slow or minimal cognitive skills for daily decision making, required minimum assistance from staff for transferring, dressing, toilet use and personal hygiene, and was incontinent (control) of bowel and bladder functions due to dementia
A review of the Physician Orders for Life-Sustaining Treatment (POLST is a physician order that outlines a plan of care reflecting a resident's wishes concerning care at life's end) dated 11/18/14, indicated Resident 1 wished an attempt of (CPR) and full treatment for prolonging life by all medically effective means.
A review of the nurse's noted dated 6/26/2017 at 2: 30 a. m., indicated Resident 1 was noted in bed asleep, offered assistance to the bathroom, no assistance needed at this time. Progress notes also indicated at 7 a. m., found resident unresponsive, lying on her right side with head on the proximity of the night stand corner, no pulse and no breathing, lying in moderate amount of blood oozing from the right side of resident's head. Resident sustained 3 centimeters by 3 centimeters laceration to the forehead. At 7: 30 a. p m., 911 was called for assistance. 911 arrived after 35 minutes and pronounced the resident dead. There was no documented evidence indicating the resident's vital signs were assessed, or CPR was initiated and or code blue was called. Failure to initiate CPR immediately after the facility's staff realized that Resident 1 was breathless and pulseless, resulted in insufficient of oxygen to the resident's brain.
A review of the clinical records of 35 sampled residents indicated 22 residents were identified as a full code status per the physician's orders. However, upon interview with the DON on 6/12/2017, at 12 p. m., she stated the facility does not have a crash cart, but promised to order one and educate staff on how to use it.
On the same date at 12:30 p. m., during and interview with the administrator in room (3c), he stated he received a text message on his phone from the DON at approximately 8 a.m. stating that Resident 1 was found on the floor, unresponsive, in a pool of blood oozing from her head and was pronounced dead by the paramedics. In an interview with the administrator, he was asked, when a resident is found unresponsive and breathless what should be done? He stated CPR was not necessary at the time resident was found because she had expired for quite some time. The Administrator further stated, staff failed to call code blue, get the crash cart and then, initiate CPR.
On 6/7/2017 at 1: 45 p. m., in an interview CNA 1 stated she went to resident 1's room on 5/26/2017 at 7: 15 a. m., opened the privacy curtain to offer her milk and coffee because the resident preferred coffee and milk in the morning. CNA 1 stated Resident 1 was found on the floor with her head raised on the metal bar part of the over bed table, breathless and pulseless, laying in a pool of blood oozing from her head. CNA 1 stated she ran out of the room, shouted LVN 1'S name. When CNA 1 was asked what else she did, CNA 1 stated she continued to pass the breakfast trays to the rest of the resident. CNA 1 was asked when a resident is found unresponsive and pulseless what would she do? CNA 1 stated she was instructed by the director of staff development not to touch the resident, leave the resident and get help from charge nurse.
On 6/7/2017 at 2: 07 p. m., during an interview with LVN 1, he was asked, how he assessed Resident 1 when he first saw the resident on the floor unresponsive. LVN 1 stated, he shook the resident's leg, "are you ok", but the resident remained unresponsive. LVN 1 stated he instructed LVN 2 to call Emergency Response Team (911), and then he stayed with the resident. He said after 911 was called, LVN 2 came back to the room and stayed with the resident and he left to resume his morning shift assignment, blocked the room and kept all the other residents in the dining room until the fire department arrived at 9 a. m. When asked why didn't he initiates CPR? LVN 1 stated CPR was not provided due to his assessment of the resident being unresponsive. LVN 1 was asked how he conducted resident's assessment, LVN 1 stated by visual observation. When asked it vital signs were taken, LVN 1 stated, Resident 1?s skin was cold, blue and stiff when he felt with his gloved hand. When asked if he was aware of resident's full code order, LVN 1 responded yes but there was "no sign of life".
On 6/9/2017 at 10 a. m. to 12 p.m., during an interview with LVN 2, she stated on 5/25/ 2017 Resident 1 was observed during rounds at 11 p. m. in her room lying in bed. At 1 a. m. on 5/26/2017, he saw Resident 1 in bed. At 3 to 3: 30 a. m. he offered Resident 1 a trip to the bath room but the resident refused and stated she was ok. He stated the last time he did rounds and saw Resident 1 sorting the magazines on her night stand top drawer at 5 a. m. on 5/26/2017. On 6/9/2017, at 11a. m., LVN 2 was questioned regarding Resident 1's activity prior to her being discovered on the floor "dead" LVN 2 stated Resident 1 usually had the ability to make her self-understood and usually had the ability to understand others. She ambulates to the bath room sometime with assistant but sometimes uses pull- ups. During an interview with LVN 2 at 12 p. m., LVN 2 stated on 5/26/2017 at 7:05 a. m, CNA 1 who worked the morning shift found Resident 1 on the floor when she went to the room to offer her breakfast, but unfortunately, found the resident unresponsive lying on the floor in a pool of blood, oozing from the right corner of her head in the proximity of the night stand metal plate that was attached to the drawers as hand holders. LVN2 was asked when a resident found unresponsive and breath less what should be done? LVN 2 stated he would check the resident's vital signs, call a code blue, call for help, and check the resident's medical record to ensure if the resident is a DNR or a full code, then start CPR. When questioned why he did not initiate CPR? LVN 2 stated CPR was not immediately initiated due to the color of the residents face and she had expired for quite some time. When asked how did he know, LVN 2 stated there was no sign of circulation, and her body was cold and stiff. LVN 2 stated, at 7: 30 a.m. he was instructed by LVN 1 to call Emergency Respond Team (ERT) who arrived at 7: 35 a. m. and pronounced the resident dead. LVN2 stated, the local police was notified and he informed the Corner office at 10 : 15 a. m.
On 6/9/2017 at 1:10 p. m., during an interview with CNA 4, Can 4 stated rounds were done on 5/26/2017 at 11 : 30 p. m., and she saw the resident in bed. CNA 4 stated the last time he saw Resident 1 was on 5/26/2017 at 4 a. m. sitting on her bed with legs on the floor. He stated the resident usually used the restroom by herself and even dressed herself. CNA 4 stated Resident 1 uses a cane when walking and held onto objects like a bed or bed table when sitting to a standing position. CNA 4 stated he left the facility at 6:55 a. m. on 5/26/20217 and he was not aware of Resident 1's death until his return to work.
On 6/12/2017 at 6:02 a. m., during an interview with CNA 4 when asked when a resident is found unresponsive what should be done, CNA 4 stated he was instructed by DSD not to touch the resident, go and get help from the charge nurse. When asked if CNA 4 knows how to perform CPR, CNA 4 stated to administer "twenty chest compressions give oxygen and remove tight clothes and open the mouth.
On 6/14/2017 at 3 : 25 p. m., in an interview with the director of nursing, she stated if the resident was found with a change of condition, the staff should have checked the vital signs; if the resident was not breathing, staff should have performed CPR and administered oxygen.
The facility policy and procedure revised April 2011 and titled ?Emergency Procedure - Cardiopulmonary Resuscitation" indicated CPR is immediately initiated in cases of recognized cardiac and or pulmonary arrest until medical emergency personnel are available to take over the resuscitation efforts. The first certified CPR staff to arrive and find a resident unresponsive and breathless and pulseless will identify whether there is cardiopulmonary or respiratory arrest by shaking the person and calling his or her name. Respond to the resident immediately and send available staff to call 911, and return for help. The policy does include the most recent changes from the American Heart Association ( C-A-B- chest compressions, airway, breathing).
According to the American Heart Association Adult Basic Life Support for Healthcare Providers Manual dated 2016, when the resident is unresponsive with no breathing or no normal breathing, the first step is to check for alertness, Start compressions, check airway check breathing, check pulse, shout for help/Activate emergency response system. Procedures include placing hand on lower half of the sternum (breast chest area); giving 30 compressions in less than 15 and no more than 18 seconds; Compresses at least 2 inches (5 centimeters) and ensure the chest rises that would indicate the resident is receiving the oxygen. Give two breaths with a bag - mask device - a method of delivering rescue breath at one second. Compression should be resumed in less than ten seconds.
The facility failed to provide care and services and provide care which meets professional standards by failing to:
1. Provide cardiopulmonary Resuscitation (CPR) for Resident 1, who was a full code in accordance to the Physician?s Order for life- sustaining Treatment (POLST).
2. Follow the facility's policy and procedure titled "Emergency Procedure- Cardiopulmonary Resuscitation"
3. Follow the American Heart Association Guidelines for Adult Basic Life Support for Healthcare providers.
The facility?s failure to provide cardiopulmonary Resuscitation (CPR) for Resident 1, who was a full code, did not afforded the Resident the opportunity to survive and receive the full benefit of CPR per her request. Consequently, Resident 1 expired at the facility.
The above violation was a direct proximate cause of the death of Resident 1. |
| 060000026 |
Seal Beach Health and Rehabilitation Center |
060013535 |
A |
6-Oct-17 |
KUND11 |
27100 |
F314: 42 CFR 483.25(b)
(b) Skin Integrity -
(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
The facility failed to ensure the necessary care and services were provided to prevent the development of pressure ulcers and promote the pressure ulcer healing processes for five of 26 sampled residents (Residents 2, 10, 12, 22, and 23) as evidenced by:
* The facility failed to identify, assess, and provide treatments and interventions for Resident 10's facility-acquired pressure ulcers. As a result, Resident 10 developed a Stage 2 pressure ulcer on the sacrococcyx, which deteriorated to a Stage 3. In addition, Resident 10 developed four additional pressure ulcers on the buttock areas that were not assessed, care planned, monitored for their healing progress, and communicated to the attending physician for proper treatments.
* Resident 12 was identified as high risk to develop skin breakdown due to diagnoses of severe peripheral artery disease and noncompliance due to dementia. Resident 12 did not have preventative measures for his heel initiated before he developed a blood filled blister. The LVN determined the wound was an arterial ulcer 24 days after being identified, without a diagnosis from the physician.
* Resident 22 was admitted to the facility without a pressure ulcer and identified as high risk to develop skin breakdown due to immobility and ESRD. Resident 22 developed a Stage 1 left heel pressure ulcer 10 days after admission, which deteriorated to an UTD blood filled blister five days later. The preventative measures were not initiated until after the ulcer was identified.
* Resident 2 was identified as high risk to develop skin breakdown; however, her heels were not offloaded as a preventative measure. As a result, Resident 2 developed a new Stage 2 left heel pressure ulcer.
* Resident 23 was admitted to the facility without a pressure ulcer and was identified as high risk to develop skin breakdown due to PVD and DM. The facility failed to put preventative measures in place to prevent the development of the pressure ulcers, such as offloading the heels or use of heel protectors. As a result, Resident 23 developed bilateral heel blisters 24 days after admission and was unable to participate in PT for transfer training to improve strength and balance due to the pressure ulcers.
Findings:
Review of the facility's P&P titled Prevention of Pressure Ulcers revised 9/2013 showed:
-Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time, causing increased pressure.
-The most common site of a pressure ulcer is where the bone is near the surface of the body.
-If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected.
-Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident.
-The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed.
-Interventions and preventive measures included: Allow resident to use a side rail as an enabler if indicated. When in bed, every attempt should be made to "float heels" (keep heels off of the bed). Use pillows, wedges or other off-loading devices to keep bony prominences such as knees or ankles from touching each other.
1. Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown - Clinical Protocol revised 3/14 showed in part: "Assessment and Recognition: 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure ulcer including location, stage, length, width and depth, presence of exudates or necrotic tissue."
Clinical record review for Resident 10 was initiated on 8/22/17. Resident 10 was admitted to the facility on 4/6/17, with diagnoses including difficulty in walking, malnutrition, incontinence, and dehydration.
Review of Resident 10's Admission/Readmission Nursing Data Tool dated 4/6/17, showed the resident did not have pressure ulcers when she was admitted to the facility and the Braden Scale showed she was at risk for developing a skin/pressure ulcer.
Review of the Quarterly Risk Assessments dated 7/13/17, (over three months after her admission date) showed the resident was still at risk for developing a skin/pressure ulcer.
Review of the Wound Evaluation Flow Sheet dated 7/14/17, (over three months after her admission to the facility) showed the resident acquired a Stage 2 pressure ulcer on the sacrococcyx.
Review of the IDT Wound Management Assessment dated 7/19/17, showed the resident had a facility-acquired Stage 2 pressure ulcer on the sacrococcyx.
Review of the IDT Wound Management Assessment dated 8/10/17, (22 days after the last IDT Wound Management Assessment) showed the resident's Stage 2 pressure ulcer had become worsened and was now a Stage 3 pressure ulcer.
Review of the Wound Evaluation Flow Sheet dated 8/19/17, showed the resident continued having one Stage 3 pressure ulcer on the sacrococcyx.
Review of the resident's care plan showed a care plan problem dated 8/6/17, titled Pressure Ulcer: Altered skin integrity related to the sacrococcyx Stage 3 pressure ulcer. The goal was to minimize the risk for further pressure sore. The interventions included to assess weekly progress of the pressure ulcer and observe/report new areas of pressure sore, open areas, or redness. However, there were no assessed needs and/or interventions to include any pressure relief devices to relieve the pressure on the sacrococcyx/buttock areas and facilitate the healing process for the Stage 3 pressure ulcer on the sacrococcyx.
On 8/22/17 at 1310 hours, an interview was conducted with LVN 5. LVN 5 stated Resident 10 acquired one pressure ulcer at the sacrococcyx after her admission to the facility and the pressure ulcer became worse from a Stage 2 to the current Stage 3.
On 8/22/17 at 1430 hours, an observation of Resident 10's wound dressing change was observed with LVN 5 and CNA 5. Before LVN 5 changed the resident's wound dressing, LVN 5 asked the resident if she was in pain. Resident 10 stated she was in pain in the wound area and it hurt. LVN 5 postponed the wound dressing change.
On 8/22/17 at 1625 hours, (two hours after the first attempt at dressing change) an interview was conducted with LVN 5. LVN 5 stated Resident 10 was still complaining of pain; the nurse had given Resident 10 her pain medication at 1430 hours (two hours earlier). LVN 5 was waiting until the pain was relieved before performing the dressing change.
On 8/23/17 at 1606 hours, an observation of the resident's wound dressing change was conducted with LVN 5 and CNA 8. After LVN 5 removed a dressing from Resident 10's buttocks, there were four additional wounds noted:
a. Wound 1: an open area measured approximately 2.5 inches (in length) x 2.5 inches (in width) on the right buttock, with slough noted around the wound edge.
b. Wound 2: an open area measured approximately 0.3 inches x 0.3 inches above the tail bone, with slough noted around the wound edge, approximately an inch away from Wound 1.
c. Wound 3: an open area measured approximately 0.2 inches x 0.2 inches on the left buttock, with slough noted around the wound edge, approximately 0.5 inch away from Wound 2.
d. Wound 4: an unopened area measured approximately 0.5 inches x 0.2 inches on the left buttock with purplish color, approximately 0.5 inch away from Wound 3.
On 8/23/17 at 1640 hours, an interview was conducted with LVN 5. LVN 5 confirmed the findings. When asked what the stages were for Wounds 2 and 3, LVN 5 stated they were Stage 3 pressure ulcers because of the presence of slough. LVN 5 stated she noted the three new wounds (Wounds 2, 3, and 4) last Friday (five days earlier), but she did not document her findings in the resident's clinical record. LVN 5 confirmed there was no documented evidence to show the new pressure ulcers were assessed, care planned, monitored for their healing progress, and communicated to the attending physician for proper treatments.
Review of the IDT Wound Management Assessment dated 8/18/17, failed to showed assessments, treatments, and other interventions for the newly acquired pressure ulcers (Wounds 2, 3, and 4).
Review of the Wound Evaluation Flow Sheet dated 8/19/17, failed to show assessments, treatments, and other interventions for the newly acquired pressure ulcers (Wound 2, 3, and 4).
Review of the Weekly Nursing Progress Note dated 8/19/17, failed to show the identifications of the newly acquired pressure ulcers (Wound 2, 3, and 4).
2. Medical record review for Resident 12 was initiated on 8/22/17. Resident 12 was admitted to the facility on 2/1/17.
Resident 12's History and Physical Examination dated 2/1/17, showed diagnoses, including severe peripheral artery disease with left below the knee amputation.
On 8/23/17 at 0815 hours, Resident 12 was observed sitting up in bed eating breakfast. Resident 12's left leg was amputated below the knee. Resident 12's right leg was crossed over his left with his right heel resting on the bed and a dressing covering his heel. There were no off-loading devices on the bed.
On 8/23/17 at 0823 hours, an interview was conducted with CNA 4. CNA 4 verified Resident 12 had a wound on his heel. CNA 4 stated Resident 12 had a boot to relieve pressure on his heel, but he took it off. CNA 4 found the boot in Resident 12's closet and stated it must not have been on last night.
Review of Resident 12's MDS dated 4/29/17, showed he needed limited assistance from one person for bed mobility and transfers. Resident 12's MDS dated 7/30/17, showed he had declined and now needed extensive assistance from one person for bed mobility and transfers.
Review of the Wound Evaluation Flow Sheet dated 7/14/17, showed a blood filled blister was identified on Resident 12's right posterior heel measuring 4 cm (length) x 5 cm (width) x UTD (depth). The area to document the stage of the wound was blank.
Review of Resident 12's Order Summary Report dated 7/24/17, showed a physician's order dated 7/14/17, for a right posterior heel blood blister, apply Betadine (antiseptic) and dry gauze, and wrap with Kerlix dressing daily times 21 days.
Review of Resident 12's physician's progress note dated 7/18/17, showed there was a new area of blistering on the right heel and evidence of deep tissue injury due to pressure. The impression was a pressure ulcer of the right heel with stage indeterminate. "There appears to be deep tissue injury."
Review of Resident 12's Order Summary Report dated 7/24/17, showed a physician's order dated 7/18/17, to apply a Prevalon type air boot (padded heel protector) to the right foot when in bed to protect the heel (four days after the blood blister was identified).
Review of Resident 12's physician's order dated 8/7/17, showed to cleanse the right heel arterial ulcer with normal saline, pat dry, and apply Santyl (enzymatic debriding ointment) daily for 21 days.
On 8/23/17 at 0900 hours, an interview was conducted with LVN 5. LVN 5 stated Resident 12 was at high risk to develop a pressure ulcer due to severe peripheral artery disease and noncompliance with elevating his leg. LVN 5 verified Resident 12's wound started as a blood blister on 7/14/17. LVN 5 stated she had not staged the blood blister as UTD, she simply stated it was a blood blister. LVN 5 stated she determined the wound to be an arterial ulcer due to the arterial ulcer on the anterior portion of his foot and clarified the order on 8/7/17 (24 days after the blood blister was identified). LVN 5 stated Resident 1 went out of the facility to see a physician who assessed the wounds. LVN 5 verified the physician had not determined the diagnosis for the right heel ulcer as an arterial ulcer. When asked to see documentation regarding preventive measures initiated for Resident 12 prior to developing the blood blister, LVN 5 was unable to locate anything.
On 8/23/17 at 1230 hours, an interview was conducted with RN 1. RN 1 verified Resident 12 was at high risk for skin breakdown due to severe peripheral artery disease and dementia. RN 1 confirmed the physician's order for Resident 12's right heel wound, written on 8/7/17, as an arterial ulcer and the physician's progress note dated 7/18/17, identified the wound as a deep tissue injury due to pressure. RN 1 verified the physician needed to determine the diagnosis if it was an arterial ulcer. RN 1 verified her nursing progress note dated 7/14/17 at 1505 hours, showed awareness of Resident 12's noncompliance and reminders being given, but no other interventions documented.
On 8/24/17 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 12 was at high risk to develop a pressure ulcer and was noncompliant by refusing to wear shoes when self-propelling the wheelchair and removing the boot that protected the heel. The DON verified the noncompliance was not included in the care plan problems. The DON stated a blood blister should be identified/staged as UTD. The DON was able to locate two occasions in the nursing progress notes where the nurse stated Resident 12 was instructed or elevated the right foot on 7/9/17 at 0940 hours and 7/10/17 at 1052 hours. The DON verified no other documentation was located regarding the preventative measures being initiated before the blood blister was identified. The DON stated the care plan problem interventions were increased/initiated after the breakdown was identified.
3. Medical record review for Resident 22 was initiated on 8/24/17. Resident 22 was admitted to the facility on 8/5/17, with diagnoses of pulmonary edema, respiratory failure, and ESRD on hemodialysis.
Review of Resident 22's clinical record titled Admission/Readmission Nursing Data Tool dated 8/6/17, showed:
- The resident did not have pressure ulcers to her bilateral heels when she was admitted to the facility.
- The resident's Braden Scale showed she was at risk for developing a skin/pressure injury.
Review of the MDS dated 8/12/17, showed Resident 22 needed extensive assistance from one person for bed mobility.
Review of Resident 22's Wound Evaluation Flow Sheet dated 8/15/17, identified a left heel Stage 1 pressure ulcer, measuring 4 cm (length) x 4 cm (width) x 0 cm (depth). An entry dated 8/20/17, identified the left heel with a deep tissue injury pressure ulcer, measuring 5 cm x 5 cm x 0 cm.
Review of Resident 22's care plan showed a care plan problem dated 8/8/17, titled Pressure Ulcer/ skin integrity related to impaired mobility, ESRD on hemodialysis, and episodes of incontinence. The interventions showed to:
- minimize skin friction/rubs/shearing
-handle gently
-encourage to get out of bed every day as tolerated
-keep clean and dry.
Review of Resident 22's care plan problem dated 8/15/17, (when the Stage 1 to left heel pressure ulcer was identified) titled Pressure Ulcer: Altered skin integrity related to pressure ulcer on left heel showed interventions to:
- float heel(s) with pillow while in bed if indicated
- apply heel protectors to bilateral heels when in bed.
Review of Resident 22's physician's order dated 8/15/17, showed to offload bilateral heels with pillow while in bed.
Review of Resident 22's physician's order dated 8/17/17, showed to apply bilateral heel protectors to both feet when in bed.
On 8/24/17 at 0825 hours, an interview with Resident 22 was conducted. Resident 22 confirmed she had a sore on her left heel. Resident 22 stated she did not have much feeling in her feet so she did not have pain. Resident 22 stated she had never had a sore on her heels before. Resident 22 stated the facility started elevating her foot after she got the sore and then started with the heel protectors.
On 8/24/17 at 0835 hours, an interview was conducted with LVN 7. LVN 7 stated Resident 22 usually lay in bed with the head of the bed up and did not like to be turned.
On 8/24/17 at 1015 hours, an interview was conducted with CNA 15. CNA 15 stated the treatment nurse told him when he needed to offload a resident's heels. CNA 15 stated Resident 22 liked to lay flat in the bed and did not like to turn. CNA 15 stated he could not remember if he elevated Resident 22's heels before she developed a pressure ulcer. CNA 15 stated he did not document if the residents heels were offloaded.
On 8/24/17 at 1500 hours, an interview was conducted with the DON. The DON verified there was no documentation regarding preventive measures for Resident 22's heels before the pressure ulcer was identified. The DON stated once the pressure ulcer was identified, they increased the care plan by adding the interventions, such as offloading and applying the heel protectors. The DON confirmed documenting of the interventions started after the pressure ulcer was identified.
4. Medical record review was initiated for Resident 2 on 8/22/17. Resident 2 was admitted to the facility on 3/15/13, and readmitted on 6/13/17, with diagnoses of dementia, Stage 2 pressure ulcer to the sacrococcyx, recent weight loss, and a new GT insertion.
Review of Resident 2's MDS dated 6/20/17, showed Resident 2 had severe cognitive impairment, needed extensive assistance with bed mobility and transferring, and had impairment on both sides of her lower extremities.
Review of the Admission/Readmission Nursing Data Tool dated 6/13/17, showed Resident 2 was readmitted from an acute care hospital with a new GT and a Stage 2 pressure ulcer to her sacrococcyx area.
Review of the Braden Scale for Predicting Pressure Ulcer Risk dated 6/14/17, showed Resident 2 was at risk for developing a skin/pressure injury.
Review of the IDT Wound Management Update form dated 6/30/17, showed Resident 2's sacrococcyx pressure ulcer resolved on 6/28/17, and to continue the plan of care for skin management.
Review of Resident 2's care plan showed a care plan problem with a revision date of 6/15/17, addressing Resident 2's risk for pressure ulcer/impaired skin integrity. The goal was to have skin that showed/demonstrated healing. The interventions included to check every two hours for soiling and wetness, keep clean and dry, minimize skin friction, and monitor nutritional status. The care plan failed to show to offload the heels with a pillow.
Review of the Change in Condition Form dated 7/28/17, showed Resident 2 had a left medial heel fluid filled blister that was first observed on 7/28/17. The summarization of the observation at the time the blister was discovered failed to show Resident 2 had a pillow in place to offload her heels.
Review of the Wound Evaluation Flow Sheet dated 7/28/17, showed Resident 2 had a left medial heel fluid filled blister documented as a Stage 2 pressure ulcer first observed on 7/28/17.
Review of Resident 2's physician's orders dated 7/28/17, showed the following orders:
- Bilateral heel protectors while in bed. May remove during care every shift.
- Offload heels with pillows while in bed every shift.
On 8/23/17 at 1040 hours, an interview was conducted with CNA 2. When asked about the pressure ulcer prevention, CNA 2 stated prior to Resident 2 acquiring the pressure ulcer on her heel, she checked Resident 2 every two hours to make sure she was clean and repositioned Resident 2. CNA 2 stated she did not offload Resident 2's heels until after the pressure ulcer to her heel was discovered. CNA 2 stated Resident 2 needed assistance for turning and repositioning and could not do it on her own.
On 8/23/17 at 1105 hours, an interview and concurrent observation was conducted with LVN 6 while at Resident 2's bedside. LVN 6 stated Resident 2 was at very high risk for developing a pressure ulcer. LVN 6 stated Resident 2 was very weak and lethargic due to her history of dehydration and decreased oral intake and stated Resident 6 had improved since the GT was placed. LVN 6 was asked what interventions were in place to prevent the pressure ulcers. LVN 6 stated turning and repositioning Resident 2 every two hours and keeping her clean and dry. LVN 6 stated Resident 2's heels were not offloaded with pillows until after the pressure ulcer to her left heel was discovered.
5. Medical record review for Resident 23 was initiated 8/2/17. Resident 23 was admitted to the facility on 6/23/17, with diagnoses including DM and PVD.
Review of the MDS dated 6/30/17, showed Resident 23 was cognitively intact and needed extensive assistance with ADL care.
On 8/24/17 at 0750 hours, Resident 23 was observed in bed, awake, lying on her back with the call light within reach. The bed was observed without the side rails or assistive devices.
Review of the Admission/Readmission Nursing Data Tool dated 6/23/17, showed Resident 23 was identified at risk for developing a skin/pressure injury.
Review of the SBAR Communication Form dated 7/17/17, showed a CNA observed a blister on Resident 23's left heel and no pillow was noted in place to float the heel at the time the blister was found.
Review of the Wound Evaluation Flow Sheet dated 7/17/17, showed Resident 23 had left and right heel fluid filled blisters. The heels were mushy and boggy with purplish discoloration.
On 8/24/17 at 1435 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 was asked when Resident 23 developed the bilateral heel blisters. LVN 6 stated Resident 23 developed the bilateral heel blisters while in the facility on 7/16/17, and the new physician's orders were written on 7/17/17, to treat both pressure ulcers on the heels. LVN 6 was asked if Resident 23 was a high risk for developing pressure ulcers and what measures were used to prevent the occurrence. LVN 6 confirmed Resident 23 was identified as high risk through the nursing admission assessment, but specific measures to prevent the development of pressure ulcers were not included in the plan of care. LVN 6 stated it was not understood why the resident developed heel blisters because she moved well and walked. LVN 6 verified offloading the resident's heels should have been included in the resident's plan of care as a preventative measure as she was identified as requiring extensive assistance.
On 8/25/17 at 0830 hours, an interview was conducted with CNA 9. CNA 9 was asked to explain what Resident 23's care needs were. CNA 9 stated Resident 23 needed assistance with all her ADL care because she was weak and scared to turn over in bed for fear of falling. Resident 23 was alert and could reposition herself, but she would not move because she did not have side rails. CNA 9 stated Resident 23 was able to walk with the walker and he talked with the nurses about Resident 23's request for side rails, but they stated "the State doesn't want anyone to have side rails."
On 8/25/17 at 0845 hours, an interview and concurrent medical record review was conducted with ADON 1. ADON 1 was asked the process of evaluating the residents for the use of side rails. The ADON 1 stated the IDT team decided to remove all the side rails on the empty beds first. Then the team removed all the side rails from the residents who did not need them and the team decided which residents should have a grab bar or pole. ADON 1 was asked how Resident 23 was assessed for the use of assistive devices. ADON 1 reviewed the Admission Assessment dated 6/23/17, for side rail usage and it showed Resident 23 did not need the side rails. DON 1 was asked if Resident 23 was assessed for assistive devices. ADON 1 confirmed no assessment was completed for the use of side rails or other assistive devices and she did not know if the PT assessed the need for a grab bar. ADON 1 was asked if Resident 23 requested side rails to assist with repositioning herself. ADON 1 stated she did not know if Resident 23 asked for the side rails.
On 8/25/17 at 1050 hours, an observation and concurrent interview was conducted with Resident 23. Resident 23 was observed in bed without the side rails or assistive devices. Resident 23 was asked if she was able to reposition herself in bed. Resident 23 stated she was afraid to move in bed because she might fall and she asked the nurses several times to put the side rails on the bed, but nothing happened. Resident 23 stated she needed the side rails to help move her body around.
On 8/25/17 at 1130 hours, an interview and concurrent medical record review was conducted with PT 1. Review of the Physical Therapy Plan of Care dated 8/22/17, showed Resident 23 was referred to physical therapy for transfer training after sustaining a skin tear on the right lower leg. Resident 23 required maximum assistance of two persons with transfers and was unable to walk due to fluid filled blisters to the right and left heels. Documentation showed Resident 23 would benefit from skilled PT services to improve strength, balance, improve ability to transfer from the bed to the wheelchair and gait with less burden for care and with proper orthotic device to prevent further skin injury to the lower extremities. The Physical Therapy Plan of Care also noted therapy necessity for noted decline in transfer training. Documentation showed without therapy, Resident 23 was at risk for further skin injury, development of joint tightness/contracture, and further decline in functional mobility. PT 1 confirmed Resident 23 was receiving range of motion exercises only because she had blisters on the heels and she could not walk.
On 8/29/17 at 1330 hours, an interview was conducted with PT 2 for Resident 23. PT 2 was asked if Resident 23 was evaluated for assistive devices to assist with mobility in bed. PT 2 stated no, she evaluated Resident 23 specifically for mobility related to the skin tear on her leg and the IDT decided if a resident needed the side rails or assistive devices. If these devices were needed, the IDT would call for a physician's order.
The above violation 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 physician harm would result. |
| 910000330 |
SHARON CARE CENTER |
910013617 |
A |
15-Nov-17 |
ZVCR11 |
12858 |
F-309
CFR 483.25 Quality of Care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences.
On 7/31/17 an unannounced visit was made to the facility to investigate a complaint regarding Resident 1's delayed transfer to a General Acute Care Hospital (GACH).
Based on interview and record review, the facility failed to ensure Resident 1, who had history of several surgeries due to vascular (blood vessels) ruptures and abdominal bleeding, was provided with the necessary care and services consistent with professional standards of practice and in accordance with the comprehensive plan of care and clinical needs, including:
1. Failure to implement the facility's policy on Pain Management and Resident 1's plan of care regarding pain risk, by not accurately evaluate Resident 1's pain, by not assessing pain characteristics, possible causes of the pain, effectiveness of intervention, and by not documenting the pain and interventions.
2. Failure to implement Resident 1's plan of care regarding abdominal discoloration and mass, by not monitoring the area for changes suggesting complications from recent surgery and diagnoses.
3. Failure to implement the facility's policy on Notification of Change of Condition by not relaying to the physician or designee, a complete and accurate status of Resident 1's condition and pertinent information to ensure the physician's orders met Resident 1's clinical needs.
4. Failure to ensure radiological tests were done stat (immediately) as ordered, by not having a policy addressing the timeliness of stat x-rays.
As a result, Resident 1's emergent transfer to a General Acute Care Hospital (GACH), underwent emergent surgery, and caused Resident 1 emotional anguish, anger, and sleep problems. The delay in transferring to a GACH, placed Resident 1 at great risk of severe complications including death.
A review of the closed clinical record indicated in the Admission Record Resident 1 was initially admitted to the facility on 3/31/17 and readmitted on 4/24/17, after a GACH stay from 4/10/17 to 4/24/17 Resident 1's diagnoses including surgical aftercare following surgery on the circulatory system, ruptured abdominal aortic aneurysm (AAA - an enlargement of the aorta, the, the main blood vessel that delivers blood to the body, at the level of the abdomen), hypertension (high blood pressure), paroxysmal atrial fibrillation (irregular, rapid heart rate), and acute embolism and thrombosis of deep veins of the lower extremity (blood clots in a leg).
A review of the Plan of Care initiated 4/2/17, developed for Resident 1's risk of alteration of comfort due to pain, included in the interventions to evaluate pain characteristics: quality, severity, location, and precipitating/relieving factors, utilize pain scale (rating scale of pain from zero to 10, zero indicating no pain and 10 the worst pain possible), and completing the pain assessment per protocol.
A review of the History and Physical (H&P) for Skilled Nursing Facility signed by Physician 1 and dated 4/3/17, indicated Resident 1 had a history of known AAA status post (s/p) multiple prior aortoiliac [aorta and iliac (groin area) arteries] endovascular and open repairs, had a right axillary-bifemoral graft (connecting the arteries near the armpit and near the groin) on 3/16/17, and was recently hospitalized (3/15/17 - 3/31/17) when the resident complained of acute back pain and was found with an endoleak [blood leaks back into an aneurysm sac following an endovascular aneurysm repair (EVAR)] s/p open AAA repair. The plan was to monitor Resident 1's cardiovascular status closely. Physician 1 documented Resident 1 had the capacity to understand and make decisions.
A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated 4/7/17, indicated Resident 1 had no memory or behavioral problems and was able to communicate without difficulties.
A review of the Skin Integrity Report dated 4/25/17, indicated Resident 1 had an eight-centimeters (cm) surgical wound to the left groin, scattered discoloration to the left lower quadrant of the abdomen (LLQ - left of the midline and below the navel), and a hard mass to left lateral abdomen (the dimensions were documented as "entire area").
A review of the Plan of Care dated 4/25/17, developed for Resident 1's discoloration of the LLQ, included in the interventions monitoring for any change of condition (COC) daily for 14 days.
A review of another Plan of Care dated 4/25/17, developed for Resident 1's hard mass on the left lateral abdomen included in the interventions monitoring any COC daily for 14 days.
A review of the Progress Notes dated 4/29/17, timed at 1:30 a.m., Registered Nurse 1 (RN 1) documented Resident 1 complained of abdominal pain rated 6/10. Nurse Practitioner 1 (NP 1), was called and ordered to administer Resident 1 Norco (narcotic pain medication) one tablet every four hours as needed (PRN), a KUB (kidney, ureter, and bladder x-ray), a blood work stat (immediately). Resident 1 wanted to go to a GACH and RN 1 called NP 1, who stated to wait for the results of KUB. RN 1 documented Resident 1 was, "Quiet" and RN 1 was waiting for the KUB that would be done at 9 a.m. because of the laboratory backlog. At 6:30 a.m., (on the same day) RN 1 documented Resident 1?s family member (Friend 1) was at the facility and wanted Resident 1 to go to a GACH. RN 1 called NP 1 who ordered to transfer to the GACH.
There was no documented evidence RN 1 implemented Resident 1's plan of care related to pain risk and abdominal mass and discoloration. RN 1 did not assess Resident 1's abdomen to determine the specific area Resident 1 had pain, the type of pain, changes in the color of the abdominal skin, swelling, distension, etc., in order to relay to the physician or NP 1 a most accurate and pertinent information of Resident 1's medical condition.
According to the Progress Notes dated 4/29/17 timed at 8:30 a.m., RN 2 documented 911 was called due to Resident 1's blood pressure of 66/40 millimeters of mercury (mmHg - normal blood pressure ranges from 120/80 to 140/90 mmHg), complaint of severe abdominal pain since this morning, and a new hematoma (collection of blood outside of a blood vessel) on the abdomen. Resident has history of AAA. The heart rate was 122 beats per minute (normal range from 60 to 100 beats per minute).
A review of the Progress Notes dated 4/29/17, timed at 9:11 a.m., Licensed Vocational Nurse 1 (LVN 1) documented that at 7:35 a.m., a message was left to NP 1 regarding Resident 1's relative (Friend 1) asking to transfer Resident 1 to the GACH due to severe abdominal pain. LVN 1 notified Friend 1 the x-ray provider (for the stat KUB) was coming after 9 a.m. NP 1 ordered to transfer Resident 1 to the GACH for evaluation, but Resident 1 was transferred via 911 (paramedics - emergency transfer) due to hypotension (low blood pressure) at 9 a.m.
A review of the Medication Administration Record from 4/1/17 to 4/30/17, indicated no documentation of pain medication (Norco) was administered on 4/29/17 as ordered.
There was no documentation of pain assessment through was performed the night when Resident 1 was complaining of pain as indicated in the plan of care. This was verified by the Director of Nursing (DON) on 9/25/17, at 4:49 p.m.
According to a review of Resident 1's clinical record at the GACH, the Operative Report indicated Resident 1 underwent surgery on 4/29/17 (same day of the transfer from the facility), an emergent left groin exploration with control of bleeding and revision of right axillobifemoral bypass graft with replacement of the right femoral artery to left femoral artery limb with an eight millimeter (ml) polytetrafluoroethylene (man-made) graft.
On 7/31/17, at 2:29 p.m., during an interview, LVN 1 stated, Resident 1 was complaining of abdominal pain all night (4/29/17 11 p.m. to 7 a.m., shift) and the pain was not relieved with pain medication.
On 9/17/17, at 2:14 p.m., during a telephone interview, Friend 1 stated Resident 1 called him to the facility because he needed help getting transfer to a GACH as the nursing staff would not transfer Resident 1.
On 9/17/17, at 2:21 p.m., during a telephone interview, Resident 1 stated on 4/29/17, he was experiencing severe pain (10/10) to his back and to the abdomen. Resident 1 requested to be transferred to a GACH because he has had multiple AAA surgeries and knew the symptoms, "There was no question in my mind that it was the aneurysm." The pain was, "Absolutely intense." Resident 1 stated, "If I did not get out of there I would have died. I was so desperate to get the hell out of there, to go to the hospital." Resident 1 stated he called Friend 1 to help him get transferred. Resident 1 described the anger, anxiety and fear of dying he had that night (4/29/17) and, after four months, he continues to have. Resident 1 stated he developed sleeping problems and is depending on prescribed sleeping pills to help him sleep.
A review of the facility's policy and procedure on Pain Management, revised on 11/28/16, indicated the purpose was to maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain. If a patient has a change in pain status, complete a pain evaluation. If PRN medications are given, document on the back of the MAR and on the PRN Pain Management Flowsheet. Patients receiving interventions for pain will be monitored for the effectiveness and side effects in providing pain relief, and document the effectiveness or ineffectiveness.
A review of the facility's policy and procedure on Notification of Change of Condition, effective 11/28/16, indicated, the Center must immediately inform the patient's physician when there is need to alter treatment significantly and a decision to transfer or discharge the patient. When making notification, the Center must ensure that all pertinent information is available and provided upon request to the physician.
A review of the facility's policy and procedure on Diagnostic Test, revised on 11/28/16, indicated diagnostic test including laboratory, radiologic, pulmonary, and waived testing will be performed as ordered. Laboratory services will be available on-site seven days a week, 24 hours a day. The policy did not include the timeliness of the tests and did not address stat orders.
The facility failed to ensure Resident 1, who had history of several surgeries due to vascular (blood vessels) ruptures and abdominal bleeding, was provided with the necessary care and services consistent with professional standards of practice and in accordance with the comprehensive plan of care and clinical needs, including:
1. Failure to implement the facility's policy on Pain Management and Resident 1's plan of care regarding pain risk, by not accurately evaluate Resident 1's pain, by not assessing pain characteristics, possible causes of the pain, effectiveness of intervention, and by not documenting the pain and interventions.
2. Failure to implement Resident 1's plan of care regarding abdominal discoloration and mass, by not monitoring the area for changes suggesting complications from recent surgery and diagnoses.
3. Failure to implement the facility's policy on Notification of Change of Condition by not relaying to the physician or designee, a complete and accurate status of Resident 1's condition and pertinent information to ensure the physician's orders met Resident 1's clinical needs.
4. Failure to ensure radiological tests were done stat (immediately) as ordered, by not having a policy addressing the timeliness of stat x-rays.
As a result, Resident 1's emergent transfer to a General Acute Care Hospital (GACH), underwent emergent surgery, and caused Resident 1 emotional anguish, anger, and sleep problems. The delay in transferring to a GACH, placed Resident 1 at great risk of severe complications including death.
The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious harm would result to Resident 1. |
| 100000070 |
Sherwood Healthcare Center |
030013675 |
B |
6-Dec-17 |
EL6Y11 |
14061 |
F309 Provide Care/Services for Highest Well Being
483.24 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to the following:
(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
The following citation was written as a result of complaint #CA00547340. Unannounced visits were made to the facility on 8/15/17, 8/25/17, 8/29/17 and 10/16/17 to investigate a complaint regarding failure to provide pain medication to a patient on 8/6/17 and 8/7/17.
The facility failed to ensure Resident 1 was provided medications necessary to reach her highest practicable physical, mental and psychosocial well-being, when Resident 1's pain medication was not available and not given as ordered, and her blood pressure medication was not given as ordered.
This failure resulted in Resident 1 experiencing unrelieved severe pain, anxiety, and elevated blood pressure.
According to the Record of Admission, Resident 1 was admitted to the facility in late summer of 2017 following an operation to replace the resident's left hip, after sustaining a fall in which the hip was broken. Resident 1 also had a diagnosis of high blood pressure.
Review of Resident 1's clinical record included:
A general acute care hospital (GACH) Medication Discharge Report, dated 8/6/17 at 7:39 a.m., which included a physician's order for acetaminophen (a mild pain-relieving drug)-hydrocodone (a narcotic pain medicine) 10/325 (10 mg [milligram - a unit of medication measurement] of hydrocodone combined with 325 mg of acetaminophen), 1-2 tab (tablets) by mouth every 4 hours as needed for moderate to severe pain of 4 to 10 (a pain scale from 1-10 with 1 being minimal pain and 10 being extreme pain). The report also directed Resident 1 to be given lisinopril (a medication used to lower blood pressure) 40 mg, 1 tablet by mouth twice daily.
A GACH Medication Administration record, dated 8/6/17, indicated Resident 1's last administered pain medication prior to transfer to the facility was acetaminophen-hydrocodone 2 tablets, given on 8/6/17 at 12:59 p.m., for a pain scale of 5 out of 10. Resident 1's last blood pressure medication, lisinopril 40 mg, was given on 8/6/17 at 8:29 a.m., and was scheduled to be given again at 5 p.m.
A GACH Inter-Facility Transfer Record, dated 8/6/17, indicated Resident 1 was discharged alert and oriented to a facility in the same city at 2 p.m., via ambulance.
A facility Physician Order entry dated 8/6/17, directed acetaminophen-hydrocodone 10/325, 2 tablets prn (as needed) by mouth every 4 hours for severe pain. The order was transcribed by Licensed Nurse 1 (LN 1) on 8/6/17 at 6:14 p.m.
A facility Physician Order entry on 8/6/17, ordered acetaminophen-hydrocodone 10/325, 1 tablet prn by mouth every 4 hours for moderate pain. The order was transcribed by LN 1 on 8/6/17 at 6:16 p.m.
A facility Physician Order entry on 8/6/17, directed lisinopril 40 mg tablet by mouth twice a day for hypertension (high blood pressure). The order was transcribed by LN 1 on 8/6/17 at 6:20 p.m.
The facility Medication Record (MR), dated 8/6/17-8/7/17, indicated lisinopril 40 mg tablet was ordered twice a day for hypertension and was scheduled to be given at 5 p.m. on 8/6/17. There was no documented evidence lisinopril was administered.
On an Admissions Nursing Assessment, dated 8/6/17 at 7:30 p.m., LN 1 indicated that Resident 1 was alert and oriented with quick comprehension and in frequent pain with any movement. LN 1 documented Resident 1 had bowel and bladder control. LN 1 documented Resident 1's pain level as 8/10 (8 out of 10). LN 1 documented that she instructed Resident 1 to, "Practice deep breathing exercises and meditating to chase pain away."
The facility Medication Record, dated 8/6/17-8/7/17, indicated hydrocodone-acetaminophen 2 tablets by mouth every 4 hours as needed for severe pain, was documented as "held" (not given) by LN 4 at 8 p.m.
A "PRN Results and Documentation Report," dated 8/6/17 at 11:13 p.m., indicated LN 4 documented acetaminophen-hydrocodone medication was, "Held due to medication not available."
During an interview on 8/25/17 at 3:15 p.m., upon examination of this documented pain level, LN 1 verified no medications were given to Resident 1 at the facility.
A facility Physical Therapy Initial Assessment, dated 8/6/17, indicated Resident 1, required the assistance of two or more helpers to achieve a sitting position from laying down...required the assistance of two or more helpers to complete a bed-to-chair transfer, and sit to stand was not attempted due to medical condition or safety concerns.
A facility Physical Therapy Plan of Care, dated 8/6/17, indicated Resident 1 was alert and oriented, reported pain with movement of her left leg at a level of 8/10, and required 100% assistance to transfer from the bed to a chair. Precautions for Resident 1 were, "Weight-bearing as tolerated" for her left leg, and she was a high fall risk.
A facility Interdisciplinary Progress Note, dated 8/7/17 at 2:41 a.m., LN 2 documented Resident 1 was alert and verbally responsive, and complaining of pain. The note included Resident 1 refused [acetaminophen/hydrocodone] from the E-Kit (emergency medication supply).
During an interview on 8/23/17 at 10:15 a.m., the Physical Therapist (PT 1) stated Resident 1 reported 8/10 pain with left leg movement during physical therapy on the evening of 8/6/17. PT 1 stated pain was prohibiting Resident 1 from participating in physical therapy activities, including getting up to a wheelchair.
A Narcotic Emergency Drug Kit inventory sheet issued on 7/26/17, and delivered to the facility on 8/2/17, showed the E-Kit contained hydrocodone/APAP (acetaminophen-a non-aspirin pain reliever) 5 mg/325 mg tablets, 8 tablets, and hydrocodone/APAP 10 mg/325 mg tablets, 8 tablets.
An observation of the Station 1 E-Kit on 8/29/17 at 10:30 a.m., showed the kit was sealed with a locking mechanism, and had an issue date of 7/26/17 and a delivery date of 8/2/17. The E-Kit was observed to contain 8 sealed tablets of acetaminophen-hydrocodone 5/325, and 8 sealed tablets of acetaminophen-hydrocodone 10/325.
Review of the yellow E-Kit sign-out sheets revealed no medication was withdrawn from the E-Kit for Resident 1.
During an interview on 8/29/17 at 10:35 a.m., LN 1 acknowledged the Station 1 E-Kit contained acetaminophen-hydrocodone 10/325, 8 tablets, and acetaminophen-hydrocodone 5/325, 8 tablets. LN 1 stated, upon visual inspection of the E-Kit, it did not appear to have been opened since its issue date of 7/26/17. LN 1 stated this was the only narcotic E-Kit in the facility.
Review of the E-Kit Log for August 2017 revealed no documented evidence that any hydrocodone/APAP was removed between 8/2/17 and 8/29/17.
In an interview with Resident 1's Family Member (FM) on 8/14/17 at 9:15 a.m., FM stated Resident 1, "...kept asking for pain medicine." FM stated Resident 1 continued to ask for pain medicine and was told the pharmacy was closed and she would have to "wait until tomorrow morning for medications." At this time, FM stated Resident 1 was offered plain acetaminophen [Tylenol, an over-the-counter medication].
During an interview on 8/16/17 at 8:30 a.m., LN 2 stated at approximately 11:30 p.m. on 8/6/17, Certified Nursing Assistant 1 (CNA 1) told her Resident 1 was upset and asking for pain medication. LN 2 stated she had offered Resident 1 plain acetaminophen once, which the Resident refused. LN 2 stated she offered (Norco) at approximately 1 a.m. LN 2 stated Resident 1 was very angry and stated she did not want the medication and wanted to go back to the hospital. There was no documented evidence the medication had been removed from the E-Kit for Resident 1.
During an interview on 8/23/17 at 1:15 p.m., CNA 1 stated Resident 1 was in a lot of pain, and she must have answered Resident 1's call light, "20 times," on the night shift of 8/6/17 into 8/7/17 (10:30 p.m. to 6:30 a.m.). CNA 1 stated there were 3 nurses at the desk whom she informed of Resident 1's pain, stating Resident 1, "Needed help and was having a really hard time." CNA 1 stated that it seemed like there was an issue with getting the medication and that no one was giving Resident 1 her pain medication. CNA 1 stated a couple of hours were spent going back and forth between Resident 1 and the nurses. CNA 1 stated that Resident 1, "Got to a point where she just wanted out," with Resident 1 stating she wanted to go back to the hospital where they could give her pain medicine. CNA 1 stated Resident 1 requested several times to call her family and was, "Really suffering." CNA 1 stated Resident 1 was shaking and incontinent of urine on one occasion due to pain, and tried to get out of bed herself stating, "I'm going to walk out of here." CNA 1 informed the nurses that Resident 1 was demanding to get up to use the phone. CNA 1 got Resident 1 out of bed and took her to the nurse's station to use the telephone where Resident 1 left a message for her family and then called 911 at approximately 2 a.m., and requested to return to the hospital where she had been discharged 12 hours earlier.
Review of GACH "Prehospital Call Report," dated 8/7/17 at 2:17 a.m., indicated Resident 1's blood pressure while in transit back to the hospital was 159/87 (normal systolic [top number] range is 100-140, normal diastolic [lower number] range is 60-90) and her pulse was 120 (normal range is 60-90.) The report further indicated Resident 1's pain level was 10 out of 10 and a re-take of her pulse was 126.
Review of GACH "Emergency Documentation - MD," dated 8/7/17 at 2:20 a.m., indicated Resident 1 arrived in the emergency room alert and oriented, complaining of left hip pain at a level of 10 out of 10, which started 3 hours earlier, and was worsening and constant. Resident 1's blood pressure on arrival was 142/116. The note further indicated Resident 1 told the GACH staff, "The staff at [the facility] tried to give her 'pills that weren't hers.'" At the time of her re-admission back into the hospital, Resident 1 had been without pain medication for over 13 hours.
During an interview on 8/25/17 at 8:30 a.m., LN 2 stated she introduced herself to Resident 1 between 12 a.m. and 12:30 a.m. and Resident 1 was not agitated at that time. LN 2 stated CNA 1 came to her with the Resident's pain medication request at approximately 12:30 a.m. LN 2 stated she took the "bubble pack" (packaging in which a card holds multiple, individual doses of medication in plastic "bubbles") from the E-Kit into the room to show Resident 1 it was acetaminophen-hydrocodone. LN 2 stated it was approximately 1 a.m., when Resident 1 refused the medication and stated she wanted to go to the hospital and to call her family. LN 2 stated she explained to the Resident she would need to get up in a wheelchair to use the phone at the nurse's station. LN 2 stated Resident 1 tried to get up by herself and was very agitated. LN 2 stated she asked CNA 1 to get Resident 1 up in a wheelchair and take her to the phone. LN 2 stated the Director of Nursing (DON) was called three times during this event and, "was very angry." LN 2 stated DON said, "Oh my God. She hasn't had pain medicine? What are you guys doing?"
An undated, facility Pain Assessment and Management policy indicated under the heading, "Purpose: To assess, evaluate, and manage the Resident's pain and discomfort."
California Code of Regulations (CCR), Title 22, Section 72355(a)(1)(B)(C) indicated, "...drugs used to treat severe pain, nausea, agitation, diarrhea or other severe discomfort shall be available and administered within four hours of the time ordered...all new drug orders shall be available on the same day ordered unless the drug would not normally be started until the next day."
During an interview on 10/16/17 at 12:30 p.m., the DON verified Resident 1 did not receive any pain medication or lisinopril during the stay. The DON described moderate pain as level 4 to 6 out of 10, and severe pain as level 7 to 10. The DON stated she did not understand the staff's hesitation to open the E-Kit to give the medication, which had been ordered and was available in the facility.
Therefore, the facility failed to ensure Resident 1 was provided medications necessary to reach her highest practicable physical, mental and psychosocial well-being, when Resident 1's pain medication was not available and not given as ordered, and her blood pressure medication was not given as ordered.
This failure resulted in Resident 1 experiencing unrelieved severe pain, anxiety, and elevated blood pressure.
These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents. |
| 970000043 |
ST. JOHN OF GOD RETIREMENT AND CARE CENTER |
910013610 |
AA |
22-Nov-17 |
56PU11 |
10640 |
? 483.24 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
F309 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.
F157 483.10 (b) (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-
(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).
On May 31, 2017, an unannounced investigation was conducted at the facility after the Department received a complaint on May 30, 2017, about Resident 1?s sudden and unexpected death on March 17, 2017, and the Director of Nursing (DON) was informed of the category of allegations.
Based on interview and record review, the Department determined that the facility failed to:
1. Ensure Resident 1 was thoroughly assessed when there was a change of condition that consisted of having shortness of breath,
2. Ensure Resident 1?s health status was reassessed and monitored following the change of condition, and
3. Ensure Resident 1?s physician was notified about the change of condition in accordance with the facility?s policy and procedures.
As a result of these failures, Resident 1 was not thoroughly assessed and monitored for the change of condition when exhibiting signs and symptoms of trouble with breathing. Resident 1 was not provided appropriate medical interventions in a timely manner, leading to an emergency transfer to the general acute care hospital (GACH) and death due to severe sepsis (a life-threatening complication of an infection).
A review of Resident 1?s clinical records indicated an admission to the facility on March 7, 2006 and was readmitted on May 11, 2015, with diagnoses including dementia (a group of thinking and social symptoms that interferes with daily functioning), cerebral vascular accident (stroke), muscle weakness, and dysphagia (difficult swallowing).
The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated March 16, 2017, indicated Resident 1 was non-verbal, was rarely understood and or understood others, the vision was highly impaired, and there was a short and long-term memory problem. The MDS assessment indicated Resident 1 required total care from staff for all activities of daily living, such as bed mobility, transfer, eating, and toilet use.
A review of the Nurses Progress notes, dated March 17, 2017 at 1 a.m., indicated Resident 1 was found by Licensed Vocational Nurse (LVN 1) with "loud breathing." LVN 1's notes indicated Resident 1's oxygen saturation (O2 Sat, a measurement of oxygen level in the blood) levels was at 90 percent (%) without oxygen (normal oxygen saturation values are 97% to 99%). Resident 1's head of the bed was elevated (HOB), oxygen was administered at 2 liters per minute (L/min) and breathing treatment was given, resulting in O2 Sat increasing to 96 %. There was no documentation about Resident 1's vital signs (respiratory rate, effort exerted while breathing, and auscultation [listen using a stethoscope] of breath sounds) being obtained to ensure Resident 1 was getting enough oxygen. There was no documentation about the Resident 1?s body temperature and heart rate to ensure Resident 1 was not having an infection or dehydration (happens when the body does not have as much water as it needs). There was no documentation about Resident 1?s level of consciousness (a measurement of a person's arousability and responsiveness to stimuli from the environment). The notes indicated that at 3 a.m., Resident 1 was "asleep." There was no documentation about Resident 1?s arousability, O2 Sat, breathing, heart rate, and temperature. At 5:15 a.m., the notes indicated Resident 1 was breathing through the mouth and belly and was unable to be awakened. Resident 1?s vital signs were documented as followed: blood pressure 90/59 millimeter per mercury (mmHg) (normal blood pressure 120/80 mmHg), heart rate was 131 beats per minute (normal 60 - 100 beats per minute) and respirations 48 (normal respiration 12 - 20) breaths per minute. Resident 1 was placed on 15 liters of oxygen through a non-rebreather mask (a device used in medicine to assist in the delivery of oxygen therapy) and paramedics was called. At 5:35 a.m., the paramedics arrived and assessed Resident 1?s vital signs as follows: blood pressure of 102/69 mmHg, heart rate of 142 beats per minute, finger stick blood sugar (test for sugar in the blood) was 131 milligrams per deciliter (mg/dl) (normal blood sugar between 70 - 99 before meals) and O2 Sat was at 95 %. Resident 1 was transferred to GACH at 5:55 a.m. The notes indicated from 1 a.m., to 5:35 a.m., Resident 1?s physician was not notified of the change of condition.
A review of the GACH History and Physical notes, dated March 17, 2017 indicated Resident 1 was having shortness of breath, comatose (a state of deep unconsciousness) and unresponsive. Resident 1?s blood pressure was 108/75 mmHg, with respiratory rate of 37 breaths per minute and temperature of 102 Fahrenheit. The laboratory results indicated Resident 1?s blood urea nitrogen (test to detect how well the liver and kidneys are working) was 40 mg/dL (normal 7 to 20 mg/dL). The white blood count (the cells that help fight infection) was very high at 36.2 1000/mcl (microliters, normal 4.0 - 11.0 x 1000/mcl) with bacterial growth of Escherichia coli (bacteria found in lower intestines) and Klebsiella pneumoniae (blood infection). Resident 1 was given Vancomycin 1.25 grams (strong antibiotic) and Zosyn 3.375 (strong antibiotic) intravenous ([IV] given through the vein) antibiotics along with three liters of IV hydration. On the same day at 4:09 p.m., Resident 1 was pronounced dead because of no detectable pulse and or respirations.
During a telephone interview on June 9, 2017 at 10:07 a.m., LVN 1 stated as he was making rounds on March 17, 2017, between 1 to 2 a.m., Resident 1's O2 Sat was between 88 - 90 %. LVN 1 stated he raised the head of Resident 1?s bed and administered oxygen at 2 L/min. LVN 1 stated Resident 1?s O2 Sat increased to 95 - 96 %. LVN 1 stated he notified the Registered Nurse (RN 1) and was told to continue administering the oxygen. LVN 1 stated at around 4 to 5 a.m., Resident 1 was observed getting worse so RN 1 was called to assess Resident 1?s vital signs and 911 (emergency response team) was called.
On August 30, 2017 at 3:55 p.m., during a telephone interview, RN 1 stated they were alerted about Resident 1 having shortness of breath (SOB) around 5 or 6 a.m. on March 17, 2017. RN 1 stated Resident 1?s vital signs were taken, and the lungs were checked. RN 1 stated Resident 1?s oxygen was increased and was placed on a non-rebreather mask.
On October 12, 2017 at 11 a.m., during a telephone interview, the DON stated according to her investigation, LVN 1 told RN 1 about Resident 1 being administered oxygen. LVN 1 told RN 1 that Resident 1?s O2 Sat was raised. The DON stated LVN 1 did not recheck Resident 1 until 5:15 a.m., which was when RN 1 stepped in and assessed the resident. The DON stated upon interview with LVN 1, aside from the O2 Sat, Resident 1?s other vital signs were not assessed. The DON stated at 3 a.m., LVN 1 told her he just visually saw but did not even touch Resident 1. The DON stated LVN 1, at the minimum, should have assessed Resident 1?s vital signs, including his lung sounds. The DON further stated RN 1 should have asked LVN 1 about Resident 1?s vital signs to determine if further interventions were needed. The DON stated Resident 1?s physician was never notified of the resident?s change of condition.
According to the facility's policy and procedures titled, "Change of Condition," revised July 2014, indicated the policy was to ensure the proper assessment and follow through for any resident with a condition change. The policy indicated the change of condition is a sudden and marked change in vital signs, behavior (changes to: lethargic [abnormal drowsiness], agitated, anxiety, refusing care, non-responsive), output (low urine output, vomiting), congestion or shortness of breath, and change in level of consciousness. The general documentation guidelines indicated to observe the resident's findings; emergency care provided for notification of the physician and documenting the observations of the resident until condition is stable.
A review of Resident 1's Certificate of Death, dated March 2017 indicated the immediate cause of death was severe sepsis.
The facility failed to:
1. Ensure Resident 1 was thoroughly assessed when there was a change of condition that consisted of having shortness of breath,
2. Ensure Resident 1?s health status was reassessed and monitored following the change of condition, and
3. Ensure Resident 1?s physician was notified about the change of condition in accordance with the facility?s policy and procedures.
As a result of these failures, Resident 1 was not thoroughly assessed and monitored for the change of condition. Resident 1 was not provided appropriate medical interventions timely leading to an emergency transfer to the GACH and death due to severe sepsis.
These violations, jointly, separately or in any combination, presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and were a direct proximate cause of death of Resident 1. |
| 920000092 |
Stoney Point Healthcare Center |
920013605 |
B |
9-Nov-17 |
W8ZQ11 |
11845 |
On November 21, 2014, an unannounced visit was made to the facility to investigate a complaint regarding scabies infection (a contagious itchy skin condition caused by a tiny burrowing mite, that leads to intense itching) at the facility.
Based on interview and record review, the facility failed to maintain and infection control program designed to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of diseases and infection to residents, visitors and staff, including:
1. Failure to ensure Resident 1, who had recurrent signs and symptoms of scabies, was provided with adequate treatment to fully eradicate scabies.
2. Failure to implement the facility's policy and procedure on Scabies Prevention Program by not searching for additional cases immediately after scabies is suspected, Surveillance Report; by not notifying physicians of exposed residents for further evaluation and diagnostic procedures such as skin scrapings; by not providing notification to visitors, family or volunteers of for any exposure to scabies; and by not having an infection control committee to oversee the implementation of the facility's policy.
3. Failure to implement isolation precautions by not ensuring staff and visitors wore personal protective equipment (PPE) while in contact with Resident 1.
As a result, Resident 1 experienced recurring scabies for over five years, Resident 1 received over 18 treatment with Elimite cream (mediation that kills the scabies mite); Family Member 1 (FM 1) developed scabies; and staff, residents and visitors, in contact with Resident 1, were exposed to scabies and were placed at risk to develop scabies.
A review of the admission record indicated Resident 1 was a 66-year old female admitted to the facility on August 11, 2008, with diagnoses including contact dermatitis, schizophrenia (chronic severe mental disorder that affects how a persons thinks, feels, and behaves), and dementia (decline in mental ability severe enough to interfere with daily life).
A review of the Minimum Data Set (MDS - standardized assessment and care planning tool) dated July 8, 2014, indicated Resident 1 was severely impaired cognition (never/rarely made decisions) and was totally dependent on staff members for all activities of daily living (ADLs such as bed mobility, personal hygiene, eating, and bathing ).
A review of the clinical record between January 16, 2009 to July 24, 2014, indicated Resident 1 was treated for multiple generalized skin rashes.
- A Physician's Order dated January 16, 2009, indicated to apply Resident 1 Permethrin 5% (Elimite cream - kill).
- A Physician?s Order dated June 20, 2011, indicated to apply Resident 1 Elimite cream all over the body at night and then shower in the morning, repeat the application of Elimite cream after seven days as prophylactic (preventive) treatment.
- A Physician?s Oder dated October 18, 2011, indicated to apply Resident 1 Elimite cream from neck to feet for eight hours every week on Wednesday for four weeks, then wash off with soft towel; contact isolation (infection control measures to prevent spread of infection and include use of personal protective equipment - PPE) for 24 hours. A review of a Dermatologist (physician that specializes in skin diseases) Consultation report dated the same day, indicated Resident 1 had an empiric diagnosis (diagnosis based on clinical signs and symptoms) of scabies.
- A Physician?s Order dated September 27, 2013, indicated to shower Resident 1 prior to the application of Elimite cream to the entire body; leave Elimite on and shower after 12 hours, for prophylaxis, contact isolation precautions for 24 hours.
- A Physician?s Order dated October 22, 2013, indicated to shower Resident 1 prior to the application of Elimite cream to the entire body; leave Elimite on and shower after 12 hours, for prophylaxis; repeat the treatment every week for three more weeks; bag all belongings and send it to the laundry for 72 hours.
- A Physician?s Order dated March 19, 2014, indicated to apply Elimite cream for prophylaxis, may repeat Elimite treatment every week for four weeks; bag all belongings and send to the laundry; and contact isolation precautions. The physician also ordered one oral dose, four tablets, of Ivermectin (medication to kill mites taken by mouth) for scabies.
There was no documented evidence to indicate Resident 1, was evaluated by a dermatologist from August 8, 2013 to March 29, 2014, when Resident 1 was receiving multiple times treatment for scabies with no improvement of symptoms, in order to determine alternate and more effective treatment for Resident 1.
There was no documented evidence, when Resident 1 was treated for scabies, the facility implemented a surveillance to investigate other possible cases, origin of the infection, and evaluate exposed residents, staff and visitors.
A review of the Treatment Administration Records indicated Resident 1received a total of seven Elimite treatment in seven months, on September 27, 2013, October 22, 2013, November 5, and 12, 2013, March 19, 2014, April 5, and 11, 2014.
A review of the clinical record indicated Resident 1's signs and symptoms of scabies persisted for over one year, from September 27, 2013, when the resident was treated with Elimite for a rash, through October 7, 2014, when Resident 1 died (death not related to scabies).
The facility's policy and procedure titled "Scabies Prevention Program" dated October 16, 2011, indicated when scabies is suspected, an immediate search for additional cases should be initiated (Surveillance Report). The DON or her designee will notify the attending physician of findings to order prophylactic and treatment of scabicide treatments on exposed residents for further evaluation and diagnostic procedures such as skin scrapings. The Director of Staff Development (DSD) will provide notification to visitors, family or volunteers to see DSD for instruction to report any exposure to scabies in the home or the community. Notify visitors (spouse, family members, or friends) who may have visited the case within the past month. Under Post Treatment Assessment Section, indicated if signs and symptoms persist or intensify, or if new lesions are identified within seven to 14 days, treatment failures should be considered.
On November 25, 2014, at 6 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated she provided treatment to Resident 1, but she did not use PPE, because she did not know the resident had scabies.
On November 26, 2014, at 3:24 p.m., during an interview, Certified Nursing Assistant 1 (CNA 1), who provided direct care for Resident 1, stated she never knew Resident 1 was placed on isolation precautions, and she did not use PPE while giving care to Resident 1.
On November 26, 2014, at 4:30 p.m., during an interview, the Director of Nursing (DON) stated none of the interdisciplinary team (IDT - group of different healthcare disciplines) knew Resident 1 had scabies, and PPE was not used during care to Resident 1. The DON also stated Resident 1 did not get an order for skin scraping to diagnose scabies. The DON stated the facility did not have an infection control committee, but infection control issues are discussed in the Quality Assurance (QA) meeting.
A review of FM 1's physician's note dated November 10, 2014, indicated FM 1 was diagnosed with scabies. FM 1 complained of spreading rash for three weeks and had a recent exposure to scabies, by Resident 1, who was in a nursing home and had a rash.
A review of FM 1's written Declaration dated December 9, 2014, indicated on October 5, 2014, FM 1 went to the facility around 5 p.m. and noticed Resident 1 was covered with a rash on her arms, legs, and torso. FM 1 asked a nurse (whose name she did not remember), if Resident 1 had scabies and the nurse said no. FM 1 developed rash 10 days after being in contact with Resident 1. FM 1 was not informed of the use of PPE.
On August 5, 2016, at 5:10 p.m., during an interview, the DON stated the facility had an outbreak of scabies on October 17, 2014, ten days after Resident 1 expired.
The facility's policy and procedure titled "Scabies Prevention Program" dated October 16, 2011, indicated when scabies is suspected, an immediate search for additional cases should be initiated (Surveillance Report). The DON or her designee will notify the attending physician of findings to order prophylactic and treatment of scabicide treatments on exposed residents for further evaluation and diagnostic procedures such as skin scrapings. The Director of Staff Development (DSD) will provide notification to visitors, family or volunteers to see DSD for instruction to report any exposure to scabies in the home or the community. Notify visitors (spouse, family members, or friends) who may have visited the case within the past month. Under Post Treatment Assessment Section, indicated if signs and symptoms persist or intensify, or if new lesions are identified within seven to 14 days, treatment failures should be considered.
A review of the Centers for Disease Control and Prevention literature dated November 2, 2010, indicated diagnosis of a scabies infestation usually is made based upon the customary appearance and distribution of the rash and the presence of burrows. Whenever possible, the diagnosis of scabies should be confirmed by identifying the mite or mite eggs or fecal matter (scybala). This can be done by carefully removing the mite from the end of its burrow using the tip of a needle or by obtaining a skin scraping to examine under a microscope for mites, eggs, or mite fecal matter. However, a person can still be infested even if mites, eggs, or fecal matter cannot be found; fewer than 10 to 15 mites may be present on an infested person who is otherwise healthy.
The Prevention and Control of Scabies in California Long-Term Care Facilities by the California Department of Public Health Division of Communicable Disease Control in Consultation with Licensing and Certification literature dated March 2008, indicated persons with typical scabies generally have fewer than 50 live mites on their skin at any given time. If diagnosis and treatment are delayed, the number of live mites results in heavier or atypical infestations.
The facility failed to maintain and infection control program designed to provide a safe, sanitary and comfortable environment and to prevent the development and transmission of diseases and infection to residents, visitors and staff, including:
1. Failure to ensure Resident 1, who had recurrent signs and symptoms of scabies, was provided with adequate treatment to fully eradicate scabies.
2. Failure to implement the facility's policy and procedure on Scabies Prevention Program by not searching for additional cases immediately after scabies is suspected, Surveillance Report; by not notifying physicians of exposed residents for further evaluation and diagnostic procedures such as skin scrapings; by not providing notification to visitors, family or volunteers of for any exposure to scabies; and by not having an infection control committee to oversee the implementation of the facility's policy.
3. Failure to implement isolation precautions by not ensuring staff and visitors wore PPE while in contact with Resident 1.
As a result, Resident 1 experienced recurring scabies for over five years, Resident 1 received over 18 treatment with Elimite cream; FM 1 developed scabies; and staff, residents and visitors, in contact with Resident 1, were exposed to scabies and were placed at risk to develop scabies.
The above violation had direct or immediate relationship to the health, safety, or security of Resident 1 and all residents in the facility. |
| 140000030 |
San Pablo Healthcare & Wellness Center |
020013620 |
B |
15-Nov-17 |
F4S411 |
5025 |
? 483.25(d)(1)(2)(n)(1)(2)(3) 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 resident's choices, including but not limited to the following:
(d)Accidents. The facility must ensure that -
(1) The resident environment remains as free of accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
(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 is in violation of the above regulation by failing to:
Provide supervision of two staff to assure a safe transfer for Resident 1, who fell and
sustained a fractured hip, requiring surgery.
Review of the facility record indicated Resident 1 was admitted 3/20/13 with diagnoses including stroke, left sided paralysis, contractures (shortening and tightening of muscles and tendons) of left hand, left elbow and knee; muscle weakness and dementia (progressive disease that destroys memory and other important mental functions).
A record review of the care plan, revised on 3/16/17, indicated Resident 1's Problem/Need list included, "At risk for fall, limited mobility, poor balance, lack of awareness, forgets to call/wait for assistance ... and had a history of falls." The Approaches (interventions) listed included: "Provide an environment that supports minimized hazards over which the Facility has control, call light within reach, remind resident to use call light, bed in the low position."
A review of the Minimum Data Set Assessment (an assessment tool to guide care), dated 3/17/17, indicated Functional Status During Transfer (how resident moves between surfaces including to or from bed, chair, wheelchair): Assistance needed was, "Total dependence-full staff performance every time during entire 7-day period." The Support provided for transfer was assessed as, "3. Two plus persons physical assist." That meant that Resident 1 needed at least two staff members to transfer her from the bed to the wheelchair.
During an interview on 8/30/17 at 11:10 a.m., CNA 1 stated (when the fall happened) Resident 1 was sitting on the side of the bed and CNA 1 turned away to get another CNA to help, as she went to go, CNA 1 pulled the wheelchair close to the bed for (Resident 1) to get up. Resident 1 was sitting on the side of the bed, then fell to the floor. CNA 1 stated she tried to catch her from the back. CNA 1 stated the resident was already pretty much on the ground because it happened fast. CNA 1 stated she thought Resident 1 could hold herself up (on the side of the bed). She stated Resident 1,"Cried a little bit," and was "grabbing onto her leg."
A review of the SBAR Communication Form (change of condition documentation), dated 8/11/17, written by the Assistant Director of Nursing (ADON), indicated Resident 1 was, "Assisted to floor. According to CNA, resident was leaning forward to the right side of the bed and she tried to position her but the resident kept sliding OOB (out of bed)... Resident's right leg was under the bed frame and sustained a skin tear. 3 person assisted resident to the w/c (wheelchair)..."
"During an interview with the ADON on 8/30/17 at 3:15 p.m., the ADON stated she should have done a more detailed assessment.
A review of the SBAR form, dated 8/14/17, indicated Resident 1 had, "Left hip pain and swelling and left cheek discoloration (blue)." Results of an x-ray done on 8/15/17 at the facility showed Resident 1 had a severely comminuted (multiple fragments) fracture of the left hip. On 8/15/17 at 2:30 p.m. Resident 1 was sent to the hospital for treatment.
Resident 1 was admitted to an acute hospital on 8/15/17. The ED (Emergency Department) Provider Notes indicated Resident 1 had a fractured right hip, abrasions (top layer of skin damaged from friction) of both lower legs, bruising on the right leg. On 8/17/17 surgery was done to repair the fracture.
Therefore the facility failed to provide supervision of two staff to assure a safe transfer for Resident 1, who sustained a fractured hip requiring surgery.
This violation had a direct or immediate relationship to the health, safety, or security of patients. |
| 070001060 |
SHINRAI-FLINTDALE |
070013463 |
B |
7-Sep-17 |
Y04F11 |
6316 |
W&I 4502(b)(8)
(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.
The facility failed to prevent harm and ensure safety measures were in place to protect one sampled client (1) from a fall. On 6/27/17, Client 1 (who had a history of running away from home) went out of the facility exit doors that were left open. Client 1 had an unwitnessed fall and sustained multiple abrasions to the lower extremities and an abrasion on the right forehead. The facility also failed to follow their policy and procedure for reporting unusual occurrences/incidents to the California Department of Public Health (CDPH).
Client 1's comprehensive functional assessment (CFA) dated 4/1/17 indicated he was ambulatory, non-verbal but able to respond to simple instructions through gestures. He required someone nearby during waking hours to prevent injury/harm in all settings.
The psychologist progress review notes dated 4/27/16 indicated Client 1 had a behavior history of attempting to run away from home without supervision.
The Special Incident Report dated 6/27/17 at 6:45 p.m. indicated direct care staff noticed the living area exit door was open. The DCS then went to check Client 1's room and found out the client was not in his room. The DCS went outside to check on the client and found him sitting on the ground (the report did not indicate the exact location outside of the house).
The care plan notes dated 2/15/17 indicated Client 1 was at risk for fall due to an unsteady gait and the use of psychotropic medications (medications used to treat psychiatric conditions).
During an observation on 8/10/17 at 10:30 a.m. in the living area, Client 1 was observed with a prominent, round scar, and red skin discoloration on his right forehead, approximately two and a half by two and one half centimeters in diameter (approximately the size of a plum). Direct care staff B (DCS B) stated the client's scar and red discoloration on the forehead was due to an episode of an unwitnessed fall.
During a telephone interview on 8/11/17 at 10:50 a.m., DCS A stated that on 6/27/17 at around 6:30 p.m. she went to Client 1's room and found the client was not in his room. She stated she then went to the living room but did not see the client. She saw that the living room sliding door was left wide open. She stated she went out of the house and found Client 1 sitting on the ground near the backyard wooden exit door (exit to the street). She stated she noticed Client 1's head with a big bump and blood on his forehead. She stated she also noticed the backyard door was propped open. She stated she assisted Client 1 to get up and brought him back inside the house and noticed multiple abrasions on the client's arms and lower extremities. She stated she gave the client first aid and notified the registered nurse (RN) by telephone. When asked, DCS A stated the last time she saw Client 1 before the fall was at dinnertime around 5:00 p.m., approximately one and one half hour prior to the fall.
During observation on 8/11/17 at 11:15 a.m. with the administrator (ADM), Client 1's right and left elbows had red skin discoloration measuring 1.5 x 1.5 centimeters (cm - a unit of measurement), approximately the size of a penny. The right knee had red discoloration measuring 1 x 1 cm. The left knee had red discoloration which measured 0.5 x 0.5 cm. The right leg shin had a dry skin tear which measured one inch long and was a lighter red color. The right great toe and the second toe had dry skin abrasions and were reddish in color, measuring approximately 0.5 x 0.5 cm.
During further observation on 8/11/17 at 2:45 p.m., in the presence of DCS A, the backyard wooden door was observed propped open and the latch/locking mechanism did not automatically lock (when DCS A pushed to close it), rather the wooden door stayed propped open. DCS A stated the door latch was broken. When asked, DCS A stated she did not know how long it had been broken. DCS A further stated Client 1 would not be able to get out of the facility if the doors were locked.
During an observation on 8/11/17 from 3:00 p.m. to 4:45 p.m., while in the living room, Client 1 would intermittently stand up from the couch abruptly and move with very unsteady gait and uncoordinated body movement (almost falling).
During an interview on 8/11/17 at 4:00 p.m., the ADM stated she was informed of Client 1's unwitnessed fall. When asked if the fall was reported to the CDPH, she stated she had not reported the incident.
During concurrent record review and interview with the ADM, the facility's 3/2005 policy on "Incident Reporting" indicated the regional center, licensing, the conservator and other agencies should be notified of the incident as needed. The ADM stated she reported the incident only to the regional center. The ADM stated the incident was reportable (to CDPH) and should have been reported because Client 1 sustained a head injury and multiple injuries on his extremities. The ADM also stated she was not aware the backyard door latch/locking mechanism was broken. When asked, the ADM stated the fall was preventable because Client 1 could not run away if the living room exit door and the backyard exit door were closed and locked. The ADM acknowledged staff did not appropriately supervise Client 1 who had a previous history of running away.
During record review on 8/11/17, Client 1's data collection summary for behavior episodes of "attempting to ran away from home" documented the client's attempts to run away from home were as follows:
March 5 episodes
April 4 episodes
May 5 episodes
June 5 episodes
The facility failed to prevent Client 1 from being free from harm when the facility exit doors were left open. Client 1 managed to get out of the house unsupervised and had an unwitnessed fall. He sustained multiple injuries to his lower extremities and a head injury. The facility also failed to report the incident to the CDPH.
The above violation had a direct or immediate relationship to the health, safety or security of clients. |
| 050000554 |
SURFRIDER HOME ICF/DD-H |
050013609 |
B |
15-Dec-17 |
DTFZ11 |
1563 |
California Health and Safety Code 1418.91 (a)(b)-Failure to Report
(a) A long-term care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
(b) A failure to comply with the requirements of this section shall be a class "B" violation.
During a complaint investigation, the Department determined the facility was in violation of the above statute by its failure to report to the Department immediately or within 24 hours an allegation of abuse, when the facility did not report an allegation of abuse for 42 hours to the Department.
On 7/12/17 at 12 p.m., the Department received a complaint regarding the alleged employee-to-client abuse at the facility.
Record review revealed, Client 1 was a 34 year old female, admitted to the facility on December 3, 1990 with diagnoses including moderate intellectual disability and cerebral palsy (disorder affecting muscle and movement, resulted from brain injuries or problems with brain development before birth).
During an interview on 7/12/17, at 12:35 p.m., facility Qualified Intellectual Disability Professional (QIDP), stated she was notified of the allegation of employee to Client 1 physical abuse by Client 1's day program on 7/10/17 at 5 p.m. The QIDP stated, she sent the special incident report involving Client 1 to the Department on 7/12/17 at 11 a.m., 42 hours after she became aware of the allegation. The QIDP explained, she thought she has 72 hours to send the report to CDPH. |
| 150000230 |
SONOMA DEVELOPMENTAL CENTER D/P ICFDD |
150013452 |
B |
7-Nov-17 |
IG1G11 |
5333 |
T22 DIV5 CH8 ART 4 - 76569(a) (2) (A) Safeguards for Clients' Monies and Valuables
(a) Each facility to whom a client's money or valuables have been entrusted shall comply with the following:
(2) Each licensee shall maintain adequate safeguards and accurate records of clients' monies and valuables entrusted to the licensee's care, including the maintenance of a detailed inventory.
(A) Records of client's monies which are maintained as a drawing account shall include a control account for all receipts and expenditures, supporting vouchers and receipts for all expenditures of monies and valuables entrusted to the licensee, an account for each client and supporting vouchers filed in chronological order. Each account shall be kept current with columns for debits, credits and balance. All of these records shall be maintained at the facility for a minimum of three years from the date of transaction. At no time may the balance in a client's drawing account be less than zero.
The facility failed to maintain adequate safeguards and accurate records of client monies spent at an on grounds store/canteen. 1) There was no evidence of a detailed inventory of items purchased by clients; 2) There was no evidence of itemization of money spent for items purchased by the clients; and 3) There was no evidence of receipts for items purchased. This failure had the potential for misuse of clients' personal funds.
A document titled, "Services provided by the [store name] to [facility name]," dated 6/8/04, contained the following information: "Shopping and dining at [store name] is used to provide Life Skills Training for clients before going into the community. The [store name] provides a supportive environment for clients where they can develop and practice self-help skills in the areas of ordering food, purchasing goods, managing money, socializing, and dining behavior..."
The policy titled, "Client Trust Accounts," #401, effective 4/15, contained the following entry: Accurate records are maintained for each resident residing at [facility name], including all receipts, expenditures and supporting vouchers."
Under the heading, "Canteen Cards," canteen cards were described as a "method for residents and staff to make purchases at the [store name]." The policy and procedure showed that cards were issued at the beginning of each month; purchases should not exceed the issued monthly amount for the resident. The IDT (Interdisciplinary Team), for budget /money management, was to review and determine the amount allocated for canteen card purchases.
Under the heading "Responsibilities;" [facility name] Trust Office has the specific responsibility for maintaining and supervising the deposited personal funds of residents served and the parent, guardian, legally authorized representative, etc., as to the use and maintain adequate safeguards.
Staff A was interviewed on 9/23/16 at 10:35 a.m. Staff A stated, for a "long, long time ago in 2001," the Trust Office has given $5,000.00 (five thousand) dollars, via check, on a monthly basis to the [store name]. Staff A stated, "It was like an advance every month." An amount of money was automatically "set in the computer" and funds were taken from the clients' checking accounts. Staff A stated, depending on the capability of the client, funds in the amount of fifteen, twenty, or twenty five dollars were deducted. Staff A stated, two weeks before the end of the month, they (store name) returned the canteen cards that listed all client expenditures. If money was returned, i.e., if a client did not spend the entire monthly amount allocated, money would go back into the clients' accounts. Staff A stated, "most of the time we go over $5,000.00 so we pay additional money. Almost all the time we give them extra money."
Staff A provided documents from 2015 titled, "Purged Transaction Inquiry," for 8 clients. The documents reflected monies being deducted from client accounts on a monthly basis. The documents included dates, transaction amounts, balances, and a comment section that indicated monthly withdrawals, i.e., January canteen, February canteen, March canteen, etc. Some of the documents also indicated, "Unused canteen" where some monies were put back into the accounts. Staff A stated, "All I will see is 'canteen' and 'unused canteen' on the clients' transaction report."
The surveyor requested to view clients' canteen cards. The facility was unable to provide evidence of any canteen cards. As an example, Staff A provided the surveyor with a blank canteen card for review. Staff A stated when he received the canteen cards back from the store, there were figures on the cards that only showed a tally of the dollar amounts deducted. Staff A stated that there were no specific items listed on the card that identified what had been purchased and no receipts were provided, only a running tally of the amount spent. Staff A stated, "They would write the amounts in pencil, we relied on their reports." The canteen program stopped on 7/17/15.
Therefore, the facility failed to provide evidence of a detailed inventory of monies spent for items received and failed to provide detailed receipts.
This failure had a direct or immediate relationship to the health, safety, or security of patients. |
| 040000037 |
SIERRA VISTA HEALTHCARE |
040013500 |
B |
18-Sep-17 |
LBCD11 |
15718 |
F 224, 483.12(b)(1)
The facility must develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.
On 11/22/16 an unannounced visit was made to the Skilled Nursing Facility (SNF) to investigate Entity Reported Incident CA00511409 regarding an allegation of misappropriation of resident property.
The facility failed to develop and implement policies and procedures to prohibit misappropriation of Resident 19's property when the facility Social Services Director (SSD) withdrew funds from Resident 19's bank account without Resident 19's permission and in violation of facility policy.
As a result of this failure, Resident 19's personal funds were not protected by the facility and her bank account was debited $2,280.18 dollars without authorization. Resident 19 suffered a loss of trust in facility staff to care for her financial needs and expressed sadness and emotional distress as a direct result of the unauthorized withdrawal of funds.
Review of Resident 19's clinical record titled, "Admission Record (document containing resident personal information)" indicated Resident 19 was 62 years old and was admitted to the SNF on 7/29/16 with diagnoses that included Acute Respiratory Failure (sudden onset of serious illness affecting the lungs ability to function normally), Heart Failure (serious illness of the heart affecting the capability to pump blood to body's tissues ), and Generalized Anxiety Disorder (mental disorder resulting in feelings of dread, apprehension and uneasiness). Resident 19's clinical record titled, "Minimum Data Set (MDS) (a resident assessment tool used to plan care) dated 10/26/16, indicated Resident 19's Brief Interview for Mental Status score was 15 points out of a possible 15 points which indicated Resident 19 was cognitively (pertaining to judgement, memory and reasoning ability) intact.
On 11/22/16 at 9:42 a.m., during an observation and concurrent interview at the SNF, Resident 19 was sitting in a wheelchair. Resident 19 conversed freely and was alert and oriented to person, place and time. Resident 19 stated in early October 2016 she asked the SSD to take her to a nearby Automated Teller Machine (ATM) so that she could withdraw money from her account. Resident 19 stated the SSD had been holding her debit card in the SSD office for safe keeping and on 10/9/16 the SSD accompanied her to the ATM where she withdrew money. Resident 19 stated the SSD stood behind her while she withdrew $200 from the ATM. Resident 19 stated she gave her debit card back to the SSD for safe keeping, but she did not give the SSD her Personal Identification Number (PIN) or permission to use her debit card for purchases. Resident 19 produced three ATM receipts dated 10/9/16 as follows:
Date: 10/9/16, Time: 10:46 a.m.
Balance from checking: $1728.64
Date: 10/9/16, Time: 10:46 a.m.
Balance from savings: $17.00
Date: 10/9/16, Time: 10:48 a.m.
Withdrawal from checking
Amount Requested: $200.00
Amount Dispensed: $200.00
Terminal fee: $3.50
Total Amount: $203.50
Resident 19 stated on 11/18/16 she received her bank statement dated 10/12/16 to 11/8/16. Resident 19 stated she noticed some withdrawals from her account on the statement that she had not made. Resident 19 stated at approximately 3 p.m. on 11/18/16, she presented her bank account statement for the period of 10/12/16 to 11/8/16 to the facility Administrator (ADM). Resident 19 stated she informed the ADM because she was worried about the many ATM charges that appeared on the bank statement. Resident 19 stated she was aware the SSD had kept her bank card for safekeeping and showed the ADM the many ATM charges on the bank statement that occurred after the withdrawal of money on 10/9/16. Resident 19 stated she had provided no one with the authority to withdraw money from her account and had not authorized anyone to use her bank card at any retailer. Resident 19 provided her bank statement dated 10/12/16 to 11/8/16 and stated the following ATM withdrawals were not done by her except for the recurring charges listed on 11/3/16 totaling $58.65 for insurance and the recurring charge listed on 11/7/16 of $71.34. Resident 19 stated she had not made or authorized the remaining charges on the bank statement indicating a total amount of $1769.68 (including ATM fees of $2.50 for each transaction). The bank statement dated 10/12/16 to 11/8/16 indicated:
10/14/16 303.00 (ATM)
10/17/16 203.00 (ATM)
10/20/16 202.95 (ATM)
10/20/16 22.25 (ATM)
10/21/16 62.00 (ATM)
10/24/16 2.00 (ATM balance inquiry fee)
10/24/16 20.79 (purchase at food and liquor store)
10/24/16 103.50 (ATM)
10/24/16 203.00 (ATM)
10/27/16 30.28 (purchase at clothing store)
10/27/16 14.18 (purchase at liquor store)
10/27/16 42.95 (ATM)
10/28/16 2.00 (ATM balance inquiry fee)
10/31/16 42.25 (ATM)
10/31/16 28.96 (purchase at grocery store)
11/1/16 2.00 (ATM balance inquiry fee)
11/1/16 42.50 (ATM)
11/2/16 15.98 (purchase at variety store)
11/2/16 16.18 (purchase at fast food restaurant)
11/2/16 55.92 (purchase at liquor store with $40 cash back)
11/2/16 10.24 (purchase at liquor store)
11/3/16 32.07 (purchase at fast food restaurant)
11/3/16 28.64 (purchase at food and liquor store)
11/3/16 9.20 (recurring insurance charge authorized by Resident 19)
11/3/16 49.45 (recurring insurance charge authorized by Resident 19)
11/4/16 11.64 (purchase at a convenience market)
11/4/16 41.34 (purchase at a variety store)
11/7/16 2.00 (ATM balance inquiry fee)
11/7/16 71.34 (recurring charge authorized by Resident 19)
11/7/16 103.00 (ATM)
11/8/16 12.81 (purchase at food and liquor store)
11/8/16 82.25 (ATM)
Resident 19 stated she was very ill when she was admitted to the SNF on 7/29/16 and the facility Social Services Director (SSD) helped her with her personal affairs and held some of her cash, about $140, in the SSD office as well as her debit card. Resident 19 stated the SSD told her it was the usual practice to lock up a debit card in the SSD office and Resident 19 felt she could trust the SSD with her card. Resident 19 stated after she realized money was missing from her checking account the ADM called the fraud department at the bank and then placed a call to the SSD's home. Resident 19 stated together with the fraud department at the bank she (Resident 19) identified additional withdrawals from her checking account on dates that began before 10/12/16 and after 11/8/16. Resident 19 stated the following amounts withdrawn from her checking account were identified by her and the bank fraud department as unauthorized withdrawals:
10/11/16 - $204.50
11/9/16 - $ 42.25
11/14/16 - $ 143.50
11/14/16 - $ 42.50
11/17/16 - $ 62.75
Resident 19 stated on 11/18/16 the ADM left a message on the SSD's answering machine requesting a return call to discuss problems with Resident 19's bank account. Resident 19 stated the local police department (PD) was contacted on 11/18/16 and an officer contacted her at the facility the morning of 11/19/17. Resident 19 stated the officer took her statement, reviewed available evidence, provided a case number and filed a police report. Resident 19 stated the officer told her approximately $3,000 had been withdrawn from her account without her permission. Resident 19 stated she felt someone at the facility had withdrawn the money and she lost trust in the facility and the facility staff. Resident 19 stated she felt sad and upset that she could not trust the facility staff because she had always felt she had a good relationship with the staff; especially the SSD.
Review of Resident 19's document titled, "[Bank] Claims Assistance Center" dated, 11/21/16, indicated, "Subject: Temporary credit for your account ending in [number] ...Dear [Resident 19]: While we research your inquiry, as a courtesy, we have temporarily credited $2,227.18 to your account above..."
On 11/22/16 at 11:20 a.m., during an interview, the Assistant Social Services Director (ASSD) stated on 11/18/16 at approximately 4:45 p.m., she was informed by the ADM that Resident 19's bank account had unauthorized withdrawals. The ASSD stated she visited Resident 19 fifteen minutes later and found her to be tearful, emotional, and upset. The ASSD stated Resident 19 expressed that she was very upset because it seemed the SSD had used her debit card to take money from her bank account. The ASSD stated Resident 19 said she felt emotionally hurt because she thought she had a good relationship with the SSD.
On 11/22/16 at 1:05 p.m., during an interview, the ADM stated on 11/18/16 at approximately 3 p.m., Resident 19 reported she had discovered withdrawals on her local bank account statement which she had not authorized or done. The ADM stated she and Resident 19 called the fraud department at the bank and the bank representative went over Resident 19's account and identified multiple unauthorized transactions. The ADM stated Resident 19 was very clear on which transactions were not authorized. The ADM stated, the bank canceled the debit card used to access the account, issued a new card to Resident 19, opened an investigation and issued an event identification number. The ADM stated the SSD called her on 11/18/16 and stated she did not have Resident 19's debit card. The ADM stated she contacted the PD on 11/19/16 in the afternoon and was given a case number. The ADM stated the PD came to the facility on 11/20/16, spoke with her (ADM) and Resident 19, made copies of Resident's 19's bank statement and the facility's policies and procedures for handling resident's funds. The ADM stated the PD returned to the facility on the morning of 11/21/16 with video from Resident 19's bank where unauthorized transactions had occurred. The ADM stated that she (ADM) and Resident 19 were able to positively identify the facility's SSD at the ATM window in two separate videos. The ADM stated, she received a telephone call on 11/21/16 from the SSD stating, she (SSD) had $1400 at her house that belonged to Resident 19. The ADM stated the SSD's family member arrived at the facility at approximately 2 p.m. and presented a sealed envelope to the ADM which contained $1400 and indicated the money belonged to Resident 19.
On 11/23/16 at 11:15 a.m., during an interview Resident 19 stated, she had filed charges of fraud and identity theft against the SSD.
On 11/23/16 at 12 p.m., The ADM stated Resident 19 received a letter from the bank indicating $2,227.18 had been credited to her account because of evidence of fraud.
Review of a document titled, "Law Enforcement Report Form" dated "approved" on 11/29/16, indicated, "On 11/23/16, at 0800 hours, I [Local Police Officer, LPO] assembled an arrest team and went to the residence of suspect [SSD] ...I contacted [SSD] and arrested her at her home ...Suspect [SSD] committed several crimes as outlined in this investigation. Those crimes include identity theft, the possession of another person's credit card/bank card account information with the intent to defraud, and multiple acts of theft committed through the fraudulent use of the victim's credit/bank card to obtain cash and through unlawful ATM withdrawals and merchandise through unlawful point of sale purchases ...The victim [Resident 19] is out $2,280.18 after the suspect [SSD] committed 30 plus fraudulent cash withdrawals and purchases using the victims bank card." The report was completed by the LPO.
On 12/8/16 at 2:46 p.m., during a telephone interview, the SSD stated, in October 2016, Resident 19 gave her debit card and wallet to her to keep in the SSD office. The SSD stated it was not unusual for residents to give her purses or wallets to store in her office. The SSD stated she had been doing this "for years" for many residents. The SSD stated that she had taken Resident 19 to a local bank ATM two times in the past to withdraw money from her account. The SSD stated she was involved with Resident's 19's financial transactions including a withdrawal of $1,400 in cash. The SSD stated, "We have been doing this forever." The SSD stated that she had held wallets, purses and monies for other residents over the years. The SSD stated the business office would ask her to hold residents money and property. The SSD stated she currently had three residents' property locked up in her office. The SSD stated it was not unusual to run "financial errands" for residents. The SSD stated, she was unsure of the facility's policy and procedures and she had been doing business this way for years.
On 12/9/16 at 4:40 p.m., during an interview, the ADM stated, there was no policy or procedure that permits facility staff to access residents' personal bank accounts. The ADM stated there was not a facility policy or procedure that permitted facility staff to access resident bank accounts without written permission.
On 12/9/16 at 6:35 p.m., during a telephone interview with the LPO, the LPO stated the facility SSD had accessed Resident's 19's debit card and made multiple purchases for personal gain. The LPO stated a search of the SSD's office and car had resulted in six wallets and purses in the office and one wallet in the SSD's personal car. The LPO stated that the SSD had confessed to points of purchases identified using Resident 19's bank card. The LPO stated the SSD had been charged with Identity Theft, Credit Fraud, and three counts of Actual Use.
The facility policy and procedure titled, "INVENTORY OF PERSONAL PROPERTY" dated 03/2010, indicated"...7. Send money and valuables to business office for safe keeping. Give receipt to resident or relative. Use valuables envelope..."
The facility policy and procedure titled, "ABUSE PREVENTION" dated 03/2010, indicated "Purpose: To ensure that resident's rights are protected through implementation of the Abuse Prevention policy and procedure. Policy: Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff...TRAINING...2. The Director of Staff Development will also provide twice a year and as needed in-services to review with facility staff the Abuse Prevention Policy and Procedure...DEFINITIONS...Misappropriation of resident property...is defined as, the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent."
The facility document titled, "Course Completion History" dated 08/09/16, indicated the SSD completed "Abuse and Neglect of the Elderly-An Overview" on 07/09/15 and "Preventing, Recognizing and Reporting Abuse" on 07/20/16.
The facility document titled "[Facility] EMPLOYEE HANDBOOK" dated October 2015, indicated, "Gross Misconduct: Gross Misconduct infractions are a direct violation of the Company's standards of conduct. These infractions include, but are not limited to: 1. Abuse...fiduciary...abuse of a resident. 2. Theft: Theft, attempted theft, fiduciary malfeasance or abuse...ELDER ABUSE ...The residents of this facility each have the right to be free from...fiduciary abuse...Definitions: Fiduciary Abuse means misappropriation of a resident's private funds ..."
The facility failed to develop and implement policies and procedures to protect Resident 19 from misappropriation of property when the facility SSD withdrew funds from Resident 19's bank account without Resident 19's permission and in violation of facility policies.
The above violation had a direct relationship to the health, safety, or security of Resident 19 and therefore constitutes a Class B Citation. |
| 630015624 |
Sonoma Developmental Center |
150013430 |
B |
12-Dec-17 |
DY8V11 |
4843 |
T22 DIV 5 CH 8 ART 4 - 76525 (a)(8) 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:
(8) To be free from mental and physical abuse and free from restraint except as permitted by Section 76329.
The facility failed to comply with the above regulation when a staff "shoved" a whole sandwich into Client 1's mouth, made a disrespectful remark to Client 1 and walked away. This resulted in Client 1 to slouch down, eyes watered, face became red and increased the risk for Client 1 to choke. The facility failed to protect Client 1 from mental and physical abuse.
On 7/12/17, the facility notified the California Department of Public Health by written notice that on 7/12/17, Staff A had witnessed, during lunchtime, Staff B "shove" a whole sandwich into Client 1's mouth and Staff B made a "sarcastic" comment to Client 1.
Review of Client 1's record revealed that he was a 47 year old male
with diagnoses that included autism disorder (disordered thinking, learning difficulties, impaired intelligence, difficulty understanding and using language), mild intellectual disability, self-abusive behaviors and aggression. Further review revealed that Client 1 had strong communication abilities and receptive skills. Client 1 was able to verbally state his wants, needs and preferences to others and was capable of understanding what was said to him. Client 1 could independently feed himself without staff assistance.
Review of the facility document titled, "General Event Report" dated 7/12/17 revealed that Staff A had documented on 7/12/17, at 12 p.m., that she observed......"Holding a whole sandwich in his hand, staff proceeded to shove the sandwich into the individual's mouth. The individual's eyes got watery and face red. Staff asked the individual to say thank you in a sarcastic tone. Individual slouched and pulled away from the staff. Staff walked away."
During an interview on 8/3/17, at 10:30 a.m., Staff A stated that she had witnesses on 7/12/17, during the clients' lunch time, Staff B "shove" a whole sandwich into Client 1's mouth. Staff A stated, "I was pouring the clients' juice. I turned around and I witnessed the staff shoving the sandwich into the client's mouth. The clients' eyes were watering, his face was very red and he slouched forward. He did not choke. The staff was very rude to him and told the client to say thank you multiple times to him. The client mumbled something and the staff walked away."
During an interview on 8/3/17 at 11:15 a.m., Staff B denied that he had "shoved" a sandwich into Client 1's mouth. Staff B stated that Client 1 ate independently and required no staff assistance.
Review of the facility document titled, "Independent Living Skills Screening" dated 3/7/17, revealed that Client 1 ....."Feeds self and is independent with all eating skills."
Review of the facility document titled, "Individual Program Narrative" dated 3/16/17, under section "Nutrition/Dining" revealed that Client 1 ....."Eats very fast and is at risk for choking. He is known for indulging in excessive fluids and should be monitored."
Review of the facility document titled, "Psychology Progress Note" dated 7/12/17, at 4 p.m., revealed that Psychologist and Social Worker met with Client 1. The Psychologist documented the following during the interview with Client 1:
Psychologist: "Did someone help you eat today?"
Client 1: "He put it in my mouth."
Psychologist: "Did he push the sandwich in your mouth?"
Client 1: "Yes."
Review of the facility document titled, "Interdisciplinary Notes" dated 7/12/17, at 4 p.m., revealed the Social Worker documented during the meeting with the psychologist, Client 1 identified a specific staff that pushed the sandwich into his mouth.
During an interview on 8/4/17, at 1:10 p.m., Client 1 stated, "Yes, staff person pushed a sandwich into my mouth during lunch. I remember that."
During an interview on 8/4/17, at 2 p.m., Psychologist stated, "This client has a great memory and will remember most everyone he meets and greets. He would be considered a reliable reporter."
The facility failed to comply with the above regulation when a staff "shoved" a whole sandwich into Client 1's mouth, made a disrespectful remark to Client 1 and walked away. This resulted in Client 1 to slouch down, eyes watered, face became red and increased the risk for Client 1 to choke. The facility failed to protect Client 1 from mental and physical abuse.
These violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 630013454 |
Sorrento in the Desert |
980013488 |
A |
28-Sep-17 |
DP0F11 |
10784 |
72315 Nursing Service ? Patient Care
(f) Each patient shall be given care to prevent formation and progression of decubiti, contractures, and deformities.
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.
On 7/10/17 at 10 a.m., an unannounced visit was made to the facility to investigate a complaint regarding quality of care.
Based on interview and record review, the facility failed to ensure each patient shall be given care to prevent formation and progression of decubitus ulcers (also known as pressure sores, bedsores and decubitus ulcers, are localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction due to lack of mobility) and failed to implement written patient care policies and procedures to ensure that patient related goals and facility objectives are achieved, including:
1. Failure to implement the facility?s policy on Food and Nutrition Services by the Registered Dietitian (RD) not conducting a nutritional assessment on Patient 1 within seven days of admission and reassess Patient 1 as necessary to determine Patient 1?s nutritional needs.
2. Failure to implement the facility?s policy on Decubitus Ulcers - Causes and Prevention by not addressing nutritional measures to improve Patient 1?s nutritional status and promote healing of decubitus ulcer.
As a result, on 6/29/17, Patient 1 was transferred to a General Acute Care Hospital (GACH) for surgical debridement of a decubitus ulcer on the sacral area (large triangular-shaped bone at the bottom of the spine) that progressed from Stage I (redness not relieved by the removal of pressure) upon admission, to a Stage III [full thickness loss of skin. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed, slough (dead tissue) may be present but does not obscure the depth of tissue loss] within six weeks of Patient 1?s admission to the facility. In addition, Patient 1 developed a Stage II (partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater) to the right buttock.
A review of the Admission Nursing Evaluation dated 5/17/17 indicated Patient 1 was admitted to the facility with diagnoses including 6th cervical bone fracture (broken neck bone), left sacral fracture, and depression (mood disorder that causes persistent feeling of sadness). Patient 1 was alert, oriented, and required assistance from staff for bed mobility, dressing, toileting, personal hygiene, bathing, and transfer. Patient 1 was admitted to the facility with a Stage I decubitus ulcer on the sacral area.
A review of the Braden Scale for Predicting Pressure Sore Risk (tool used for early identification of patient at risk for forming decubitus ulcer) dated 5/30/17 indicated Patient 1 scored 15 (at high risk of developing decubitus ulcers).
A review of the admission physician?s orders dated 5/17/17 included to give Patient 1 a regular diet and to obtain the laboratory blood test complete blood count (CBC). There were no orders for nutritional supplements.
A plan of care, dated 5/17/17 and updated on 6/6/17, developed for Patient 1?s potential for skin breakdown, indicated the patient had an actual skin breakdown related to immobility, incontinence, anemia (when number of red blood cells or hemoglobin is less than normal. Hemoglobin delivers oxygen to all parts of the body), and low albumin (main protein found in the human blood and low albumin is an indicator of malnutrition). The approaches included diet as ordered. The approaches did not include RD evaluation and nutritional interventions.
A review of Patient 1?s laboratory result dated 5/19/17 indicated hemoglobin was low at 8.7 gram (g) /deciliter (dl) [reference range: 13.7-17.5 g/dl], and albumin level was low at 2.5 g/dl [reference range: 3.5-5.7 g/dl].
A review of laboratory results dated 5/31, 6/6, 6/13, 6/20, and 6/27/17 indicated the hemoglobin level remained low, ranging from 8.9 g/dl to 9.6 g/dl, and the albumin level remained low, ranging from 2.2 g/dl to 2.6 g/dl. Although Patient 1?s laboratory results indicated nutritional problems, there was no referral to the RD until 6/20/17, 33 days after Patient 1?s admission.
A review of the Skin/Wound Assessment and Treatment dated 6/4/17 indicated Patient 1?s Stage I decubitus ulcer on the sacral area progressed to a Stage II decubitus ulcer measuring 2 centimeters (cm) in length by 2 cm in width and another Stage II developed on the right buttock measuring 2 by 2 cm.
A review of the Daily Skilled Nurse?s Note dated 6/6/17, at 12:55 p.m., indicated Patient 1 had a Stage III decubitus ulcer on the sacral area and a skin tear the on right buttock.
A review of the Skin/Wound Assessment and Treatment dated 6/7/17 indicated Patient 1?s Stage III sacral decubitus ulcer measured 3 by 3 cm, had blood serum (amber-colored, protein-rich liquid that separates out when blood coagulates) drainage, pink with slough (dead) tissue, and the Stage II decubitus ulcer on the right buttock measured 3 by 3 cm.
The Skin/Wound Assessment and Treatment dated 6/15/17 indicated Patient 1?s Stage III sacral decubitus increased in size to 3.5 by 3.5 cm, with presence of odor, and the wound bed was pink, black, and yellow.
A review of Patient 1?s Nutritional Assessment completed by the dietitian on 6/20/17 (33 days after admission) indicated the RD recommended double protein portion with the current diet. The RD also documented in the Data Collection/Evaluation form, Patient 1needed increased calories and protein for wound healing. The nutrition plan was to provide regular diet with extra double portions of protein. The RD did not document an assessment of Patient 1?s daily nutritional needs.
The Skin/Wound Assessment and Treatment dated 6/22/17 indicated Patient 1?s Stage III sacral decubitus ulcer increased in size to 3.8 by 3.5 cm, had odor and the wound bed was pink, black and yellow.
The Skin/Wound Assessment and Treatment dated 6/29/17 indicated Patient 1?s Stage III sacral decubitus ulcer increased in size to 4 cm in length by 4 cm in width by 1 cm in depth, and the Stage II pressure ulcer on the right buttock measured 5 by 5 cm.
A review of a Physician?s Telephone Order dated 6/29/17 indicated to transfer Patient 1 for wound debridement (surgical removal of dead tissue to promote wound healing).
According to the GACH?s Operative Note dated 7/3/17, Patient 1 was admitted to the GACH on 6/29/17 with diagnoses including the sacral decubitus ulcer wound, stage IV (full thickness loss of skin and extends into the underlying bone and muscle). The stage IV decubitus ulcer was irregular with extension to the sacral bone, and measuring 8 cm by 6.5 cm by 2 cm with undermining of 12 cm at 3 o?clock, 4 cm at 8 o?clock and 2 2 cm at 9-10 o?clock. Patient 1 underwent a debridement of sacral decubitus ulcer, sacral bone biopsy (small sample of bone is taken and look under microscope for bone disorders), and laparoscopic (surgical procedure performed in the abdomen through small incisions with the aid of a camera) diverting colostomy (procedure which one end of the large intestine is diverted through an incision made in the abdominal wall) under general anesthesia (medications that are inhaled or received through a needle in a vein to become unconscious during a surgical procedure).
On August 8, 2017, at 3:30 p.m., during a telephone interview, Registered Nurse 1 (RN 1) stated all patients are to receive RD consultation on admission. RN 1 stated the administrator or any nursing staff should have contacted the RD for Patient 1?s nutritional evaluation. RN 1 stated Patient 1?s nutritional assessment was not completed by the RD because the RD was on vacation. RN 1 stated the facility had contracted with only one RD, and was not able to find another RD when the contracted RD was not available.
On 7/10/17, at 12:40 p.m., during an interview and concurrent review of Patient 1?s clinical record, Licensed Vocational Nurse 1 (LVN 1) was not able to provide documented evidence of a calculation of the amount of calorie, protein, and fluid Patient 1 needed daily.
According to the undated facility?s policy of the Food and Nutrition Services, the dietician would conduct nutritional assessment for each client within seven (7) days of admission and a reassessment no less than annually. The administrator may arrange consultation by the registered dietician to the direct care staff, as needed.
The facility?s policy of the ?Decubitus Ulcers-causes and prevention? dated 2/1/11, indicated the contributing factors for decubitus ulcer was poor nutritional status as in anemia (when number of red blood cells or hemoglobin is less than normal. Hemoglobin delivers oxygen to all parts of the body) and hypoproteinemia (a condition when there is abnormally low level of protein in the blood). Decubitus ulcers develop more quickly and are more resistant to treatment in patients suffering from nutritional disorder. Providing high protein diet as ordered, vitamins and protein supplements are measures to improve nutritional status and maintain a positive nitrogen balance (associated with tissue repair or muscle growth).
The facility failed to ensure each patient shall be given care to prevent formation and progression of decubitus ulcers and failed to implement written patient care policies and procedures to ensure that patient related goals and facility objectives are achieved, including:
1. Failure to implement the facility?s policy on Food and Nutrition Services by the RD not conducting a nutritional assessment on Patient 1 within seven days of admission and reassess Patient 1 as necessary to determine Patient 1?s nutritional needs.
2. Failure to implement the facility?s policy on Decubitus Ulcers - Causes and Prevention by not addressing nutritional measures to improve Patient 1?s nutritional status and promote healing of decubitus ulcer.
As a result, on 6/29/17, Patient 1 was transferred to a GACH for surgical debridement of a decubitus ulcer on the sacral area that progressed from Stage I upon admission, to a Stage III within six weeks of Patient 1?s admission to the facility. In addition, Patient 1 developed a Stage II to the right buttock.
The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious harm would result to Patient 1. |
| 010001031 |
Stonehaven |
110013592 |
B |
14-Nov-17 |
LQFN11 |
4469 |
A 045 W&I 4502(b) (8) W&I 4502
(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.
The facility failed to protect one client from harm, (Client 1) when the client was transported in his wheelchair in a facility van driven by a facility staff member who had not been trained on techniques for safe transport of clients using wheelchairs. While being transported home in his wheelchair, the van driver encountered a bump in the road and saw that Client 1 had tipped over in his wheelchair and had blood coming from a cut on the top of his head. Client 1 was taken to the Emergency Room for care. Client 1 had sustained a bump on his head and a scalp laceration which required surgical staples to close the wound.
The facility is a 6 bed Intermediate Care Facility for the Developmentally Disabled - Habilitative licensed to provide care and services to people with varying degrees of developmental disability and mental retardation. Client 1 was dependent upon the facility for basic health care needs including dental care.
Client 1's diagnoses included: Cerebral palsy, spastic quadriplegia. Client 1 required a wheelchair for mobility.
During an interview and record review on 2/03/14 at 2 p.m., the QIDP indicated that on the evening of 1/16/14, "(Client 1's name) was being transported home, from an event, in the facility van by (Direct Care Staff C's name), who was driving the van. When she, (DCS C), pulled over to get into the driveway, the bus shaked [sic] and Client 1 tipped over. He hit his head. We applied First Aid. We took him to the ER."
Per interview and record review with the QIDP on 2/6/14 at 2 p.m., Direct Care Staff C (DCS C) was the driver of the van on 1/16/14. While she, (DCS C), was driving the van home late that night with Client 1 (named) seated in his wheel chair in the back of the van, Client 1's wheel chair toppled over and Client 1 went with it (he had his lap belt on) but was not tied down with all four wheelchair tie downs, as is the standard procedure for van transport safety.
During an interview on 2/6/14 at 2:50 p.m., DCS C stated that in the eighteen months which she had worked for the facility, prior to the accident involving Client 1 on 1/16/14, she had not received training from the facility on the specific van safety measures necessary for the safe transport of clients who use a wheelchair for their mobility.
During the same interview on 2/6/14 at 3 p.m., DCS C was asked to describe the procedure she had used to secure Client 1's wheel chair to the van floor when she transported Client 1 home the night of 1/16/14. DCS C stated she had used two tie-downs to secure Client 1's wheel chair prior to transport. Upon inquiry, DCS C stated she only saw the two tie downs." DCS C stated, "There was one that hooks to the back of the wheels in the back of the van, and there is one that hooks to the front of the wheels in the front."
On 2/6/14, review of the facility Policy and Procedure titled, "Van Safety," dated 3/13, indicated: 7) "When loading someone in a wheelchair, make sure to lower the anti-tip bars when the four tie downs are attached and secured to the individual's wheelchair. 8) Check to see that all individuals in wheelchairs have their seat belts and other wheelchair supports properly fastened. 9) Once the individual's wheelchair is tied down to the van floor, lock the wheelchairs brakes." The proper procedure for securing an individual's wheelchair to the van floor for safety during transport is to apply one tie down to each of the four corners of the wheelchair frame, not to the wheels which can move, and to then cinch the tie downs tightly to the floor with the cinch clips provided.
Facility staff failed to protect the client from physical harm when DCS C applied only two tie downs to the wheels of Client 1's wheel chair instead of fastening one tie down to each of the four corners of the wheel chair frame as per facility policy. This caused Client 1's wheel chair to tip over causing the Client 1 to strike his head on the interior van resulting in Client 1's head laceration which required six staples.
This violation had direct or immediate relationship to the health, safety, or security of the patient. |
| 950000026 |
SAN MARINO MANOR |
950013504 |
B |
18-Sep-17 |
M38911 |
4551 |
?483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81ø Fahrenheit;
On 8/3/16 at 7 p.m., an unannounced visit was made to the facility to conduct a re-certification survey.
Based on observation, interview, and record review, the facility failed to maintain safe and comfortable temperature levels for a total of 11 Residents (Residents 1, 2, 3, 13, 15, 16, 17, 18, 21, 22, and 23) in Rooms 27, 28, 29, 30, and 31, after the air conditioning (AC) unit malfunctioned during two days.
As a result, Residents 1, 2, 3, 13, 15, 16, 17, 18, 21, 22, and 23 were exposed to excessive heat with ambient temperatures ranging between 81.9 degrees Fahrenheit (øF) to 90.2 øF, placing the residents at risk for complications such as dehydration (excessive loss of body water) and discomfort.
On 8/3/16 at 7:30 p.m., during the initial tour of the facility accompanied by licensed vocational nurse (LVN 1), the hallway by Rooms 27, 28, 29, 30, and 31, felt noticeably warm. The hallway and rooms temperatures were measured.
The following temperatures were taken with a thermocouple (equipment to take room temperatures) with LVN 1 present:
Resident 2?s room temperature reading was 87.8 degrees øF.
Resident17?s room temperature was 88.6 øF.
Residents 1, 3, 13, 15, 16, 18, 21, 22, and 23 residing in Rooms 27 31 had room temperature readings between 84.3 øF to 90.2 øF.
The hallway outside rooms 27 31 was 87.8 øF.
During the observation and measurement of the rooms? temperature, there were portable electric fans in each of the five rooms but the air circulating was hot/warm air. The windows were open one to two inches and were not able to open any further to allow cooler air from the outside to circulate to the inside of the residents? rooms.
Residents 1, 3, 13, 16, 18, 21, 22, and 23 were unable to participate in interviews due to their mental condition.
During an observation and concurrent interview, on 8/3/17 at 7:40 p.m., Resident 15 was sitting on his bed with his T shirt half up his back. Resident 15 stated the temperature in the facility was always hot.
During an interview, on 8/3/17 at 7:40 p.m., LVN 1 stated she knew there were problems with the AC unit recently, but believed someone had fixed it already.
On 8/3/17 at 7:42 p.m., during an interview, the Administrator stated they just installed a new AC unit and were having problems with it off and on since June 2017. The Administrator stated they had ordered a new motor for the unit that was supposed to arrive on 8/2/17 and had not arrived. The Administrator stated he had provided fans to residents and increased hydration to those residents affected.
On 8/3/17 at 8:21 p.m., during an interview, the Director of Nursing (DON) stated it has been hot, in the hallway where Rooms 27 to 31 are, for about two days.
Another observation of the rooms temperatures were conducted, on 8/3/17 at 8:45 p.m. and revealed:
Room 27 86.4 øF
Room 28 86.5 øF
Room 29 81.9 øF
Room 30 87.7 øF
Room 31 86.8 øF
On 8/3/17 at 9:38 p.m., the Administrator used his own ambient thermometer (temperature gun) and the temperature in the hallway and Rooms 27 to 31, was 90 øF and above.
On 8/4/17 at 5:40 p.m., during an interview, Maintenance Supervisor (MS) stated the AC completely stopped working since Wednesday (8/2/17) and he checked the temperatures in the rooms every day, but did not keep a log.
According to Weather Underground (a weather information service), the highest ambient temperature on that day (8/3/17) was 98 øF.
On 8/5/17, at 2 p.m., during an interview, the Administrator stated the facility did not have a policy on room temperatures.
The facility failed to maintain safe and comfortable temperature levels for a total of 11 Residents (Residents 1, 2, 3, 13, 15, 16, 17, 18, 21, 22, and 23) in Rooms 27, 28, 29, 30, and 31, after the AC unit malfunctioned during two days.
As a result, Residents 1, 2, 3, 13, 15, 16, 17, 18, 21, 22, and 23, were exposed to excessive heat, with ambient temperatures ranging between 84.3 øF to 90.2 øF, placing the residents at risk for complications such as dehydration (excessive loss of body water) and discomfort.
The above violation jointly, separately, or in any combination had a direct or immediate relationship to the health, safety, or security of Residents 1, 2, 3, 13, 15, 16, 17, 18, 21, 22, and 23. |
| 910000084 |
SUNNYSIDE NURSING CENTER |
910013371 |
B |
2-Aug-17 |
P8CI11 |
9895 |
F225
?483.12(c) (1)
(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility muse:
(1)Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
(2)Have evidence that all alleged violations are thoroughly investigated.
(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
The Department of Public Health (DPH) received a complaint regarding a resident (Resident 1) receiving an injury of an unknown origin of a deep left hand laceration (a deep cut or tear in the skin or flesh) injury and required a transfer to the hospital to receive eight sutures (a row of stitches to hold together the edges of a wound) to close the wound. The facility?s staff stated they did not know how the injury was sustained.
The facility failed to:
1. Implement its written policy regarding reporting injuries of unknown origins
2. Report to the DPH Resident 1?s injury of unknown origin.
This failure of not reporting Resident 1?s injury of unknown origin, of a left hand deep laceration, placed the resident and other residents at risk for possible injuries.
A review of Resident 1's Admission Face Sheet indicated the resident was a 98 year-old female who was admitted to the facility on 5/24/10. Resident 1's diagnoses included vascular dementia (change in memory, thinking, and behavior from damage to the brain) and Alzheimer's disease (progressive disease that destroys memory and other important memory functions).
A review of Resident 1's Minimum Data Set (MDS), a standardized resident assessment and care-screening tool, dated 11/28/16, indicated the resident had severe cognitive impairment for daily decision-making skills with a Brief Interview for Mental Status (BIMS) score of 00 (a score of 00 to 07 indicates severe impairment). According to the MDS, Resident 1 was non-ambulatory, incontinent of bowel and bladder and required extensive to total assistance from the facility's staff in all activities of daily living (ADLs). The MDS indicated Resident 1 had other behavioral symptoms not directed toward others daily and did not exhibit behaviors of rejection of care.
A review of Resident 1's History and Physical assessment, documented by the physician, dated 8/27/16, indicated the resident did not have the capacity to understand and make decisions.
A review of the facility's Injury and Accident log indicated Resident 1 sustained an injury during care on 2/8/17. A review of a Situation/Background/Appearance/Request (SBAR [change in condition assessment]) and a Physician/NP/PA Communication and Progress Note for Changes in Condition, a communication used before calling the physician, dated 2/8/17, indicated the resident sustained a left anterior (front) hand laceration between the little finger and the ring finger (4th finger), measuring approximately 3.5 centimeters (cm) in length. The assessment indicated during care, at 3:50 a.m. on 2/8/17, the resident was observed holding onto the side rail crying with bleeding (approximately 20 cubic centimeters [cc]) observed to the left hand. The note indicated the resident's physician was called at 4:20 a.m. (30 minutes after being found bleeding) on 2/8/17.
A review of a Physician's Order, dated 2/8/17, and timed at 4:40 a.m., indicated to transfer Resident 1 to the general acute care hospital (GACH) for further evaluation of the deep laceration wound to the left hand.
On 3/3/17 at 9:18 a.m., during a wound care observation, done by a Licensed Vocational Nurse (LVN 1), Resident 1 was observed lying in her bed with a bandage to the left little finger. The bandage on the left little finger was dry and intact with eight (8) stitches at the crease of the little finger and palm. During a concurrent interview, Resident 1 stated when asked, she did not know how her hand was injured.
On 3/3/17 at 12:11 p.m., during an interview, the Registered Nurse (RN) supervisor, who was on duty on the 11p.m.-7 a.m. shift, the day of the incident, stated the charge nurse called her to the resident's bedside regarding a laceration between the pinky and ring finger. The RN supervisor stated she observed a deep laceration with minimal bleeding. The RN supervisor stated there were no sharp objects around and the resident was unable to tell her what happened.
At 1:25 p.m., on 3/3/17, the Director of Nursing (DON) stated after interviewing the certified nurse assistants (CNAs) and charge nurses, none of the staff was able to determine how Resident 1 sustained the hand laceration. The DON stated he looked at the resident's side rail and wheelchair the following day and did not see any sharp edges. The DON was asked why the resident's injury of unknown origin was not reported to DPH. The DON stated, "Because it was the facility's policy to only report if there was a suspicion of abuse."
On 3/3/17 at 2:30 p.m., during an interview, CNA 1, who was assigned to Resident 1 on 2/8/17 (night shift), stated she went inside the resident's room on 2/8/17 at approximately 3 a.m. to check and see if the resident was wet and needed to be changed. CNA 1 stated that while changing the resident, the resident grabbed the bed's side rail for support while turning on her side and Resident 1 started screaming. CNA 1 further stated she saw blood on the resident's side rail and called the charge nurse to check the resident's hand.
A review of an Interdisciplinary Team (IDT) Conference Record (Skin Tears/Bruises/Other Injuries), dated 2/9/17, indicated Resident 1's behaviors included episodes of resistance to care and refusal of nail care at times with long fingernails. According to the record, there were no sharp objects or jagged edges noted on the side rails and wheelchair.
A review of the GACH's records, dated 2/8/17, and timed at 6:02 a.m., indicated Resident 1 was seen in the emergency department (ED) with the chief complaint being a left hand (palm) laceration sustained at the nursing home. The ED note indicated the laceration was noted that morning with an unclear mechanism of injury. The left hand laceration was measured to be 6.4 cm in length with a depth in the subcutaneous space (situated or lying under the skin) with intermittent bleeding. The ED procedure note indicated the area was anesthetized (to give drugs so no pain can be felt).
On 6/8/17 at 3:50 p.m., during a telephone interview, Resident 1's family member (FM 1) stated the incident happened on 2/8/17 at approximately 3:50 a.m., but she did not received a call from the facility's staff until 7:30 a.m., after the resident had been transferred to the GACH. FM 1 stated Resident 1 received eight sutures to close the deep laceration to her left hand. FM 1 stated she was upset because the facility?s staff could not tell her what happened. She stated after the incident, Resident 1 who was right-handed, was "very" protective of the injured left hand. FM 1 stated she checked the resident's bed and wheelchair for sharp, jagged edges, but none were found.
On 6/12/17 at 11:16 a.m., during a telephone interview, the facility's Compliance Officer (CO) stated Resident 1 had a high risk for injuries due to her combative behavior. The CO was asked about reporting unusual occurrences/ injuries of unknown origins and she stated, "We do not have to report per our facility's policy."
At 4:03 p.m., on 6/13/17, during a telephone interview, the facility's Administrator stated he thought unusual occurrences/injuries of unknown origins did not have to be reported as long as there were no bruises in areas that abuse occurs, such as inner thighs, eyes, etc. The Administrator stated, "Since the resident (Resident 1) was combative it was not suspicious in nature."
A review of the facility's policy and procedure titled, "Prevention, Reporting and Correction of Inappropriate Conduct Including Abuse, Neglect and Mistreatment of Residents and Investigations of Injuries of Unknown Origin," dated 11/2016, indicated an injury should be considered as an "injury of unknown source" when both of the following conditions are met:
1. The source of the injury could not be explained by the resident;
2. The injury is suspicious because of the extent of the injury and the location, or the number of injuries observed at one particular point in time or the incidence over time.
The policy indicated, under Reporting, the Administrator in coordination with the compliance officer would either verify or report all allegations of abuse or neglect in accordance with the State and the Federal regulations, including but not limited to the Elder Justice Act.
The facility failed to:
1. Implement its written policy regarding reporting injuries of unknown origins
2. Report to the DPH Resident 1?s injury of unknown origin.
The above violation had the direct relationship to the health, safety, or security of Resident 1 and other residents. |