| 140000078 |
Tampico Terrace Care Center |
020011660 |
B |
12-Aug-15 |
1P6O11 |
5154 |
F333-The facility must ensure that residents are free of any significant medication errors. The facility violated the aforementioned regulation by failing to ensure Resident 1 was free of a significant medication error by ensuring staff follow the facility policy and use two methods to correctly identify a resident before giving medications. On 5/16/15, Registered Nurse (RN1) gave Resident 1 medications meant for Resident 2, resulting in Resident 1 experiencing low blood pressure and a change in mentation requiring hospitalization. On 5/18/15, a relative of Resident 1 reported to the Department that Resident 1 was given the wrong medications which caused his blood pressure to drop. During a phone interview on 5/27/15, Resident 1's relative stated, "She (nurse) gave him all of another patient's medications. My mother was at the bedside and saw his (Resident 1) eyes roll up. She yelled to call 911. The nurse came in and said it was her fault, that she gave him the wrong medications." On 5/28/15, review of the medical record showed Resident 1 was admitted to the facility on 5/13/15, with diagnoses that included hypertension (high blood pressure), coronary artery disease (decrease in blood flow through the arteries to the heart), chronic kidney disease, and intracerebral hemorrhage (bleed in the brain) with resulting blindness, and hard of hearing.Review of a nurse's note, signed by RN (registered nurse) 1, dated 5/16/15 at 10:00 a.m., showed, "Administered medication to patient at approximately 8:30 a.m. Discovered I had administered the wrong medications at about 9:10 a.m. I immediately notified my supervisor and took vital signs: B/P (blood pressure) 70/40, pulse 58 and oxygen saturation (the percentage of oxygen reaching the extremities) was 95 % on room air. The patient was no longer able to respond to commands. I lowered the patient's head of bed. I explained to the patient's wife what had happened and apologized. I phoned the physician and received an order to call 911. We called 911 at approximately 9:20 a.m. Emergency services arrived 10 minutes later and the patient was out of the building by 9:50 a.m." Review of the "Post Incident Report", dated 5/16/15, showed, "Patient was given medications meant for Resident 2. He was given Hydralazine 100 milligrams (mg) (anti-hypertensive drug), Doxazosin Mesylate 4 mg. (anti- hypertensive drug), Edarbi 40 mg (anti- hypertensive drug), Amiodarone HCL 200 mg. (corrects the heart rhythm), Verapamil ER 120 mg. (anti-hypertensive that also corrects abnormal heart rhythm), Isosorbide MN ER 60 mg. (cardiac drug that prevents angina or heart pain), Lasix 40 mg. (a diuretic which increases the secretion of urine), Lovenox 40 mg (an anti-coagulant or blood thinner) and Ferrous sulfate 325 mg (iron supplement). Patient's blood pressure was monitored closely; 15 minutes later his B/P was 73/40, 5 minutes later (his) systolic blood pressure (top number) was in 60's. MD (medical doctor) was called with orders to send patient out to the emergency room 911. Wife present at bedside. Patient is DNR (do not resuscitate) but wife wants him to be sent." During interview on 5/28/15 at 12:40 p.m., the Director of Nurses (DON) stated, "RN 1 did not look at the (Resident 1's) name band and he (the resident) did not correct her when she called him the wrong name. RN 1 realized later that she made this error." Review of the hospital emergency room physician's notes, dated 5/16/15, showed, "The patient was opening his eyes and got to the ER around 10:00 a.m. and has some orientation to person. The patient was evaluated by MD. Had a CT (computerized tomography) scan with no acute lesion and ...lab and chest x-ray were ordered. The patient was presented for admission. He is following commands and able to move all extremities, although he seems very weak and his B/P was around 76 (systolic, top number) initially... Home medications: Resident 1 was on: Aspirin 81 mg (anticoagulant), Amlodipine 10 mg (anti-hypertensive), Metoprolol 100 mg (anti-angina), Losartin 50 mg (anti-hypertensive) Pravastatin 10 mg (cholesterol lowering), Levemir (insulin)." Review of the facility's policy and procedure, titled, "Identification of a Resident," revised 5/27/15, showed, "1. All residents shall be identified by an identifier (ID) bracelet on the resident's wrist or ankle as soon as possible after admission. 2. A picture of the resident will be taken by medical records staff and uploaded into the electronic medical record. 3. The staff member providing medications, treatment, diagnostic testing, etc. shall identify resident by using TWO of the following methods: a. checking arm band, b. checking photo, C. asking resident his/ her name if able to answer questions, d. asking resident his/ her birthdate, e. Checking with another staff who has provided care for the resident, f. asking friend or family member to confirm resident ID." Therefore the facility failed to ensure that staff used two methods to identify a resident prior to administering medications.The above violations had a direct or immediate relationship to the health, safety, or security of patients. |
| 020000274 |
The Rehabilitation Center of Oakland |
020011916 |
B |
19-May-16 |
L8R911 |
5253 |
F224 483.13(c) PROHIBIT MISTREATMENT/NEGLECT/MISAPPROPRIATNThe facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.The facility violated the aforementioned regulation when it failed to follow their policy and procedure to protect residents from mistreatment and neglect one resident (1) when Resident 1 went out on pass and she was not permitted to enter the facility. She was left outside the facility on 9/28/15 from 7:30 p.m. to 11:30 p.m. and had no place to go. She was scared as she hid in back of a bush, in the back of the building. As a result of this violation, Resident 1 suffered emotional distress and placed her at high risk for potential physical injury.A complainant reported to the Department of Public Health that on 9/28/15, Resident 1 was locked out of the facility from 7:30 p.m. to 11:30 p.m. An unannounced onsite visit to the facility was conducted on 9/30/15. Resident 1's record was reviewed on 9/30/15 at 1:00 p.m. According to the face sheet, Resident 1 was a 31 year old individual who was admitted to the facility from an acute hospital on 8/8/15, for an opened wound on her left arm due to cellulitis/abscess (skin infection/pocket of pus). Resident 1 was interviewed on 9/30/15 at 2:30 p.m., she stated that about two weeks ago, Staff person 5 asked the resident, "What are you going to do with yourself (after being discharged). He gave me a one way ticket to Stockton on Amtrak, a $50.00 credit card and a taxicab voucher. When I came back, they (the facility staff) wouldn't let me in. My clothes were by the trash can outside. One of the nurses came and said that I was supposed to be back by 5:00 p.m. I got back here at 7:30 (p.m.). I stayed outside in the back until 10:00 (p.m.). I was scared. I stayed in a corner, back of a bush. I thought someone was going to do something to me... I was so tired. I lay down on the concrete. My back is still hurting me. They tricked me that day. Who can I trust?" Review of "Social Service Progress Notes", dated 9/24/15 showed that Resident 1 thought she might find an apartment in Stockton and she "is planning on visiting it sometimes early next week. SS (social services) will continue to f/u (follow up) and assist as needed."During an interview with the Assistant Administrator on 9/30/15 at 1:30 p.m., she stated that on 9/28/15 at 1 p.m., Resident 1 went to Stockton to look at a couple of places. Resident 1 did not notify any of the nurses when she left. Social Services knew about it, but the social services staff did not relate it to the nurses. The resident had not come back for a long time. She took a taxicab and Amtrak.Review of Nurse's Notes dated on 9/28/15 at 10:00 p.m., showed that Nurse 4 received Resident 1 standing outside of the facility. All resident's belongings were placed outside. Resident 1 stood at the outside of the facility without leaving.During a telephone interview with Staff person 5 on 10/12/15 at 8:45 a.m., he stated, "I work as the business developer for the company. I gave her (Resident 1) an Amtrak ticket a $50.00 voucher and a taxicab voucher at 9:00 or 10:00 in the morning. Then I left. The social worker knew about this." During a telephone interview with Nurse 4 on 10/12/15 at 11:00 a.m., she stated, "At 3:00 (p.m.) when I got to work, the door in (was) locked. The day shift (staff) told me Resident 1 is going look for an apartment. She said if she (Resident 1) is not back at 5:00 p.m., she is no longer our patient... She came back between 8:00 and 9:00 p.m. and I didn't let her in. Staff person 5 came in a half to one hour (after the resident came back) and said, 'call the police. She is no longer our patient.' I went outside and talked to her for a few minutes... I told her, 'you supposed to be back at 5:00 p.m. So our facility (is) not allowing you back in.' The police officer came and I explained to the police officer. The police officer called Staff person 5, he didn't answer the phone. The police officer stayed with her (the resident) until 11 - 11:30 p.m... The night nurse let her in the facility. She stayed on the right hand side of the building until the nurse let her back in..." The facility policy and procedure titled "Abuse - Prevention Program", dated 1/1/2012, indicated, "The facility does not condone any form of resident abuse, neglect and/or mistreatment, and continually monitors Facility policies, procedures, training programs, and systems in order to maintain an environment free from abuse and mistreatment." Under Procedure, it indicated, "The facility is committed to protecting residents from abuse by anyone, including but not limited to Facility Staff ..." The facility policy and procedure titled "Resident Abuse - Recognizing Signs and Symptoms", dated 1/1/2012, indicated, "'Neglect' is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness." The facility's failure to implement their policy and procedure to protect residents from mistreatment and neglect by not allowing Resident 1 to enter the facility upon returning from pass, and left her outside from 7:30 p.m. until 11:30 p.m. |
| 020000274 |
The Rehabilitation Center of Oakland |
020013173 |
B |
1-May-17 |
IO6311 |
6222 |
F232
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 provide supervision to prevent accidents when Certified Nursing Assistant 1 left Resident 1 unattended during nursing care and Resident 1 fell from bed and sustained a broken left elbow.
During observations on 10/12/16 from 11:15 a.m. to 4:30 p.m., Resident 1 was sleeping in the bed nearest to the door of a three bed room, her left arm was in a sling, she responded to touch and voice, and was unable to participate in interview.
Review of the "Resident Admission Assessment," dated 9/13/16 indicated Resident 1 was admitted to the facility with diagnoses that included generalized muscle weakness, quadriplegia (paralysis), and a history of a broken right hip. The assessment also indicated Resident 1 required total assistance with bathing, dressing, hygiene, toileting, moving from bed to chair, walking, and had a history of falls. Resident 1 was able to follow instructions and make her needs known.
Review of the "Skilled Nursing Notes," dated 9/24/16, indicated Resident 1 needed extensive assistance with bed mobility, transfer (assistance moving from bed to chair), and toileting.
Review of the "Physical Restraint Device Assessment," dated 9/22/16, indicated Resident 1 also required the use of two hand rails to assist with turning and moving while in bed.
Review of the "Resident Care Plan Fall Risk Prevention and Management," dated 9/20/16, indicated Resident 1 was at risk for fall and had limited mobility. The goal of care was to provide a safe environment that minimized complications associated with falls. The care plan also indicated the facility was to "...provide an environment that supports minimized hazards over which the facility had control..." and to "...orient Resident 1 to the environment each time changes were made...."
During an interview on 10/12/16 at 2:45 p.m., Licensed Vocational Nurse (LVN) stated on 9/28/16 at 9:30 a.m., she asked Certified Nursing Assistant (CNA) 1 to get Resident 1 ready for wound care. LVN 1 stated she asked CNA 1 to turn Resident 1 on her right side, hold her in that position, and to stay with Resident 1 to assist LVN 1. LVN 1 stated that at 9:55 a.m., CNA 1 informed her that Resident 1 was ready (for care). LVN 1 stated CNA 1 was standing behind Resident 1 at the side of bed holding her in position for care. LVN 1 stated she was standing at the door to Resident 1's room when she heard a loud noise; she looked up and saw Resident 1 was on the floor in an "awkward" position. LVN 1 stated CNA 1 was standing at the foot of Resident 1's bed. LVN 1 also stated CNA 1 told her that she turned around to help another resident in the room.
During a telephone interview 11/10/16 at 1:30 p.m. CNA 1 said on 9/28/16 at about 9:30 a.m. she was bathing Resident 1. CNA 1 stated LVN 1 asked her to get the resident ready for wound care and have her on her right side. CNA 1 stated she told LVN 1 she was ready, "a few minutes before 10 a.m." CNA 1 stated she had Resident 1 positioned on her right side, facing the door, both side rails were up, Resident 1 was holding onto the side rail closest to the door, and the bed was in highest position. CNA 1 stated "I was behind her holding and supporting her, and waiting for the wound nurse. CNA 1 stated "suddenly, another resident called me, and I said to 'hold on'." CNA 1 stated the other resident said 'quick I need my clothes.'" CNA 1 stated she turned to the other resident for "just seconds," heard Resident 1 fall, and the wound nurse came in immediately. CNA 1 stated she went quickly to Resident 1 on the floor and asked her what happened. CNA 1 stated Resident 1 told her she moved her legs and fell over.
Review of the "Post Fall Assessment," dated 9/28/16, indicated Resident 1 was not able to move her (left) arm without pain.
Review of the "Nursing Notes and Situation Background Assessment Recommendation" (SBAR), dated 9/28/16, at 10:30 a.m., indicated a CNA (CNA 1) was assisting Resident 1 in bed "...when the roommate summoned her and asked for assist. CNA (CNA 1) left the resident (Resident 1) and went to roommate's bed resulting in resident (Resident 1) rolling off the edge of the bed and ending up on floor. Noted swelling to the (left) arm...." The SBAR also indicated the Nurse Practitioner was at the facility and ordered Resident 1 to be transported to the emergency room.
Review of the "Emergency Room Notes," dated 9/28/16, Medical Doctor (MD) 1 indicated a left Humerus (bone in lower arm) fracture was treated with immobilization (long arm splint) and referred Resident 1 to orthopedic (bone) specialist.
During clinical record review of the MD 2 orthopedic consult office visit dated 9/30/16 indicated Resident 1 had a left elbow fracture, swelling through the hand, pain and difficulty with use of left arm. X-ray revealed a severely dislocated and unstable broken left elbow.
During an interview on 10/12/16, at 12:45 p.m. the Director of Nursing (DON) stated he was present at the time of the fall, and CNA 1 used poor judgement when she left Resident 1 during care to answer a call from another resident in the same room.
According to Hegner's "Nursing Assistant Basics," the ending procedure action to lower the bed to its lowest position "...ensures patient safely. Prevents falls, accidents, and injuries...."
Review of the facility's policy and procedure titled "Fall Prevention and Management Program," dated 8/1/14 indicated "...Purpose - To provide a safe environment that minimizes complications associated with falls..." and "...supports providing an environment free from the hazards over which the Facility has control...."
Therefore, the facility violated the aforementioned regulation by failing to provide supervision to prevent accidents when Certified Nursing Assistant 1 left Resident 1 unattended during nursing care and Resident 1 fell from bed and sustained a broken left elbow. |
| 100000495 |
Tahoe Home |
030011857 |
B |
19-Nov-15 |
CMTX11 |
3689 |
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. An unannounced visit was made to the facility on 10/20/15 at 10:10 a.m. to investigate complaint number CA00462469 and CA00462635. The Department determined the facility failed to report an incident of alleged abuse when Client A was found in another client's room with his pants down. Review of Client A's clinical record revealed he was admitted to the facility on 2/4/93. His diagnoses included severe intellectual disability, impulse control disorder, and bi-polar disorder. Notes from an annual Interdisciplinary Team Conference, dated 7/23/15, were reviewed. The section titled "Additional Comments" "Sexual/Social Assessments" indicated Client A had a history of intrusive behavior/touching male peers. The assessment indicated Client A's behavior escalated while at a previous day program. He was going into the restroom while other males were occupying the stalls and attempting to touch their genitals. Client A was moved to a new day program in 2011 and the assessment indicated he had not had any incidence of inappropriate touching since that year. However, the assessment indicated he continued to require close supervision at both his day program and his residence.An Interdisciplinary Note, dated 6/11/15 at 11:30 p.m., indicated Client A went to bed at 11:35 p.m. Staff documented they heard Client B hitting his headboard and hollering. The staff documented she went to check and found Client A had crawled into Client B's bed and had his P.J.'s and underwear below his knees. When staff opened the door he got off the bed and began yelling and cursing at staff, telling her to get out. Documentation revealed about 10 minutes later, staff caught him coming out of Client C's room.Staff told him to go to his own room and he started cursing, calling her names, and finely he went to bed.No further documentation regarding the incident was found in Client A's clinical record. Client B's clinical record revealed he had severe intellectual disability. Client B did not have capacity to make decisions or give consent. Client C's clinical record revealed she had profound intellectual disability. Client C was not verbal and did not have capacity to give consent or make decisions. An interview was conducted with the Qualified Intellectual Disabilities Professional (QIDP) on 11/20/15 at 11:30 a.m. The QIDP was asked if the incident involving Client A being found with his pants down in another client's room on 6/11/15 had been reported to the Department as alleged sexual abuse. The QIDP stated the incident had not been reported to the Department. The QIDP stated the incident was not reported because "nothing happened." The QIDP stated both Client B's and Client C's clothing were intact so she didn't feel any sexual assault had been attempted. The QIDP acknowledged she could not be sure that sexual abuse had not occurred even though their clothing was intact. The facility's policy titled Abuse, Neglect and Exploitation of Resident's (undated) included, in part, the following: "All cases of suspected resident abuse are to be reported to the applicable licensing agency, local law enforcement and Ombudsman as mandated by law. All employees with resident contact are mandated reporters." The Department determined the facility failed to report an incident of alleged abuse when Client A was found in another client's room with his pants down. Failure to comply with the requirements of Health & Safety Code Section 1418.91 shall be a Class B Citation. |
| 040000064 |
TWILIGHT HAVEN |
040010716 |
B |
08-May-14 |
2IYZ11 |
4577 |
Class B Citation - Quality of Care On 1/21/14 an investigation was conducted of Entity Reported Incident #CA 00382431, regarding Quality of Care-Resident Safety/Falls.The facility failed to ensure Resident 1 (Res. 1) received adequate supervision for transfers when Resident 1's left patella (kneecap) was fractured during a transfer by Certified Nursing Assistant (CNA 1). CNA 1 used a standing lift (a mechanical device to assist in transfer, requiring resident to bear weight on legs) to transfer Resident 1. Resident 1 underwent surgery to repair the fractured left knee.Resident 1 was a 77 year-old female, diagnoses included hip surgery and osteoporosis (brittle, porous bones). Res.1 was admitted from an acute care hospital on 4/13/11, following an open reduction internal fixation (surgical procedure to repair a broken bone or joint) of her left hip.On 1/22/14 at 9:15 a.m. during an interview, CNA 1 stated on 12/31/13 at 9:30 a.m. she had helped Resident 1 to the bathroom. CNA 1 stated she used the standing lift to transfer Resident 1from the bed to the wheelchair. CNA 1 stated during the transfer, Resident 1 had started to slip. CNA 1 then braced her right knee against Resident 1's left knee and helped her to the floor. Review of Resident 1's Minimum Data Set assessment, (MDS),(an assessment tool used to determine psychosocial, cognitive and physical ability), dated 12/16/13 indicated Resident 1 was totally dependent on staff to meet all her daily needs. Resident 1 required a two-person physical assistance for transfers. Resident 1 had current physician orders which restricted her from bearing weight on her left leg. Review of the Activities of Daily Living (ADL) Flow Record indicated on the morning of 12/31/13, CNA 1 transferred the resident by herself, using the lift. On 1/22/14 at 9 a.m., during an interview the Administrator (Admin) stated Certified Nursing Assistant 1 (CNA 1) had used the standing lift to transfer Res 1. She stated Resident 1's physician's orders indicated the resident was not to bear weight on her legs, as she was a total lift. The Admin stated CNA 1 chose the incorrect lift. Review of Res. 1's Physician's Orders, dated 9/4/13, indicated:..."Non weight bearing to left lower leg." Review of Physician's order's dated 9/5/13 indicated: ... "May use Hoyer Lift (brand name for two-person lift) for transfers due to non-weight bearing to left lower leg." Review of nurses' notes dated on 1/31/14 Res. 1 had complained of pain to her left knee. The nurses note indicated Resident 1 stated, "I fell... well I didn't fall, I was going to and the CNA put her knee against mine and so I couldn't fall when I was being transferred. CNA 1 stated she did not transfer the resident by herself, she used the Standing Lift to transfer resident." On 1/22/14 at 9:25 a.m. during a concurrent observation and interview, Resident 1 sat on the bed, wearing a brace on her left leg. Resident 1 stated CNA1 tried to transfer the resident from the bed to her wheelchair, and "could not hold me up." Resident 1 stated CNA 1 "tried to put me in my wheelchair and I ended up on top of her." As a result of this incident, she had experienced increased mobility problems, and her activity level had declined. Resident 1 complained of increased pain and had required an increased amount of pain medication. The injury had caused a delay in discharge.Review of the nurses' notes dated1/2/14 at 1:30 p.m., indicated Resident 1 had complained of a score of 5 on a pain scale range of 1 to 10 (a scale to determine severity of pain where 10 is the worst possible pain) to left knee...knee swollen and hurts to touch...". Review of the nurses' notes dated 12/31/13 at 1:25 p.m., indicated the physician had ordered, "...extend Physical Therapy (PT) for five weeks for ....transfers and balance..." Review of the Manufacturer's Guidelines for use of the standing lift, indicated the Resident must bear weight on both legs and press knee-caps against a brace bar for correct operation. The Facility's failure to implement the physician's order to provide assistance in accordance with the plan of care and to use the correct lift for transfer resulted in a complete fracture of her left patella with bone fragments separated by13 millimeters. This caused Resident 1 to have increased pain, surgery, and a delayed discharge. This injury also placed Resident 1 at risk for physical decline. The above violation had a direct and immediate relationship to Resident 1's mental and health, safety, and security and therefore constitutes a Class 'B' Citation. |
| 040000064 |
TWILIGHT HAVEN |
040012275 |
B |
20-May-16 |
LK2M11 |
7224 |
F 279 483.20(d), 483.20(k)(1) DEVELOP COMPRESHENSIVE CARE PLANS The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.25; and any series that would otherwise be required under 483.25 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(b)(4).On 3/4/16 at 2:30 p.m., an unannounced visit was made to the facility to investigate an Entity Reported Incident CA00478480 regarding a resident fall with injury. As a result of the investigation, the Department determined the facility failed to: 1. Follow the Fall Management Policy and Procedures and 2. Develop, plan, and implement new interventions to prevent recurrent resident falls. These failures resulted in a wrist fracture, scalp lacerations, and a visit to the Emergency Room (ER) to Resident 1 and placed her at risk of serious harm.Resident 1 was admitted to the facility on 1/8/15, with diagnoses of history of falls, non-traumatic intracranial hemorrhage (bleeding in the brain), left sided hemiplegia (paralysis), and gait (walking) abnormalities.Resident 1's MDS (Minimum Data Set) 3.0 Assessment (a tool to collect resident health and physical assessment data) dated 1/5/16, indicated she was cognitively intact with a BIMS (Brief Interview for Mental Status -a structured memory process assessment tool) of 15 of 15 (15 meaning the resident has no cognitive deficits, cognitively intact). Resident 1 required supervision to transfer and ambulate, and utilized a walker for assistance.Resident 1's Interdisciplinary Progress Note dated 5/1/15 at 3:14 p.m., for fall (number) 1, indicated, "Resident had a non-injury fall at 1:30 p.m... witnessed by certified nursing assistant (CNA)... Resident was in w/c (wheelchair) and was being pushed to activities when Resident put her feet down and caused her to trip over her feet. Resident fell on her knees and caught herself with her hands..." Resident 1's Interdisciplinary Team (IDT) (a resident, family and staff meeting in order to discuss resident care) Notes dated 5/4/15, for fall 1, indicated, "IDT recommends to 1. Monitor for delayed trauma, 2. Monitor for pain, 3. Notify MD and RP (Responsible Party), 4. Educate resident to move and stand slowly, 5. Encourage Resident to ask for assistance when needed." Resident 1's Nurse's Notes dated 11/27/15 at 5:00 p.m., for fall 2, indicated, "Witnessed fall... Resident was walking in hallway lost balance and slowly fell down to floor..."In an interview and concurrent record review on 3/4/16 at 4:25 p.m., the DON stated Resident 1's clinical record had no IDT notes for fall 2. Nurse's Notes dated 2/6/16 at 10:00 p.m., for fall 3, indicated, Resident 1 had an unwitnessed fall. "Resident stated that she was coming out of the bathroom and fell against the window and into a sitting position. No evidence of using her walker was noted."During an interview and concurrent record review on 3/4/16 at 4:25 p.m., the Director of Nurses (DON) stated Resident 1's clinical record had no IDT notes for fall 3. Nurse's Notes dated 3/2/16 at 6:30 a.m., for fall 4, indicated, Resident 1 had an unwitnessed fall with injury. The notes indicated, "...Resident noted to be laying supine on floor... moderate hemorrhaging (bleeding) from scalp noted... Resident states that she was ambulating in her room unassisted without assistive devices and lost her balance when she fell. Head trauma noted to back of scalp, large nodule with 4cm (centimeter) (unit of measure) length laceration (cut)... Resident requesting for ER evaluation with [acute care hospital]..." In an interview and concurrent record review on 3/15/16 at 4:11 p.m., the Director of Staff Development (DSD) reviewed Resident 1's clinical assessment titled, "Fall Risk" and was unable to find any documentation of a new fall risk score after the 3/2/16 fall (fall 4), and stated, "A new fall assessment has to be performed after a fall occurs." She further stated Resident 1's fall care plan should have been updated with new interventions after each fall, per facility policy. Nurses Notes dated 3/2/16 at 12:00 p.m., indicated, "Resident returned from hospital with wrist fracture (broken bone) to left hand and two sutures to scalp... Resident will use wheelchair when up... Left wrist wrapped, clean." Nurses Notes dated 3/3/16 at 1:30 p.m. indicated, "Resident went to follow up doctor's appointment and returned with a cast (stiff material to prevent movement) to L [left] forearm... L wrist is now in a cast with slight edema [swelling] noted." Resident 1's Rehabilitation Referral Form dated 3/3/16, indicated post fracture Resident 1 was unable to ambulate with her walker secondary to left arm maintained in a sling.During an interview on 3/4/16 at 2:36 p.m., Resident 1 stated she required more staff assistance when transferring, dressing and while attempting to move in bed, since her last fall. In an interview and concurrent record review on 3/4/16 at 4:25 p.m., the DON stated Resident 1's clinical record contained no evidence of an IDT meeting held after her falls on 11/27/15 (fall 2) and 2/6/16 (fall 3). In an interview on 3/4/16 at 4:30 p.m., Licensed Nurse (LN) 1 stated Resident 1 required more assistance such as with her Activities of Daily Living (ADL's) since her fall and fracture on 3/2/16 (fall 4).Resident 1's ADL Flow Record dated 3/1/16 to 3/3/16, indicated, Resident 1's staff assistance was a "2" (limited assistance) for bed mobility, transfers, and toilet use.Resident 1's ADL Flow Record dated 3/4/16, indicated Resident 1's staff assistance increased from a "2" to a "3" (extensive assistance) for bed mobility, transfers, and toilet use. During a concurrent interview and clinical record review on 3/18/16 at 1:35 p.m., LN 1 and LN 2 stated Resident 1's fall care plan was not updated after her 2/6/16 fall (fall 3). The facility policy and procedure titled, "Response to Falls" dated 03/01/15, indicated, under post-fall assessment and monitoring, "C. Following each resident fall, the Interdisciplinary Team Falls Committee will review the Post-Fall Assessment & Assessment within 72 hours, or as soon as practicable... Based on the Post-Fall Assessment & Investigation, the IDT-Falls Committee will review fall prevention interventions and modify the plan of care as indicated." The facility policy and procedure titled, "Fall Management Program" dated 03/01/15, indicated under Care Planning, "A. The nursing staff will develop a plan of care specific to the resident's needs with interventions to reduce the risk of falls... B. The interdisciplinary Team will routinely review the plan of care at a minimum of quarterly, with a significant change in condition, and post fall." Therefore the facility violated the regulations when it failed to: Follow its Policies and Procedures for resident fall management and Resident 1 sustained several falls, one with serious injury, a left wrist fracture.These violations had a direct and immediate relationship to the health, safety, and security to Resident 1, and therefore constitute a class "B" citation. |
| 040000076 |
The Terraces at San Joaquin Gardens Village |
040012662 |
B |
19-Oct-16 |
EYUQ11 |
7556 |
F 279: 483.20(k) Develop Comprehensive Care Plan A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.25; and any services that would otherwise be required under 483.25 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(b)(4). The facility failed to implement Resident 1's comprehensive care plan for a wander guard (an alarm system designed to alert staff when a cognitively impaired resident wanders outside alarmed doorways). This failure allowed Resident 1 to go outside unnoticed and unsupervised; where she fell and sustained a laceration to her forehead and an injury to her right shoulder. On 6/16/16 and 7/5/16, unannounced visits were made to the facility to investigate the Entity Reported Incident CA00491502. Resident 1 was an 86 year old female who was admitted to the facility on 03/20/10. Resident 1's diagnoses included Alzheimer's disease (cognitive impairment and memory loss) and a history of falls. Resident 1's Minimum Data Set (MDS - measure of resident's level of function and health care needs) assessment dated 12/22/15, indicated Resident 1 had long and short term memory impairment. Resident 1's "Wandering Risk Assessment" dated 11/20/14, indicated Resident 1 was at "High Risk" for wandering. Resident 1's "Wandering Risk Assessment" dated 2/8/16, indicated Resident 1 was "High Risk" for wandering and was forgetful, had a short attention span, did not understand what was being said, had a history of wandering and was a "known wanderer." Resident 1's "Fall Risk Assessment" dated 3/20/16, indicated Resident 1 had a score of 13 which indicated the resident was at a "HIGH RISK" for falls. The assessment indicated Resident 1 was disoriented at all times, was chair bound, and had balance problems while standing. Resident 1's Physician orders, dated 2/17/14, indicated, "Monitor episodes of wandering every shift." Physician orders, dated 1/1/16, indicated, "Wander guard in place on wheelchair to monitor self-propelling in wheelchair outside the [facility] unsupervised every shift." Resident 1's care plan focus, dated 10/10/11, indicated, "The resident is at risk for falls r/t [related to] Unaware of safety needs and impair mobility, cognitive loss, unable to make decisions..." The care plan goal indicated, "resident will be free from major injury due to falls..." The care plan intervention, initiated 2/15/13, indicated, "...pressure sensor pad alarm. Ensure the device is functional and is in place in w/c [wheelchair]... at all times..." Resident 1's care plan focus, dated 10/14/14, indicated, "The resident is an elopement [leaving without anyone knowing] risk/wanderer..." The care plan goal indicated, "The resident will not leave facility unattended..." The care plan intervention, initiated 1/1/16, indicated, "Is wander guard in place and functional?" On 6/16/16 at 4:25 p.m., during an observation and concurrent interview with the Director of Nurses (DON) in the facility dining room, Resident 1sat in a wheelchair. Resident 1 had fading bruises around the left eye, stitches on her forehead, and a sling supporting her right arm. The DON confirmed Resident 1 had five stitches in her forehead to repair a laceration and her right arm was in a sling. The DON stated both injuries were sustained from a fall that occurred on 6/9/16. On 6/16/16 at 4:40 p.m., during an interview, Licensed Nurse (LN) 1 stated on 6/9/16 at 9:40 p.m., she exited through the door to the courtyard, and returned 10 to 15 minutes later. LN 1 stated when she returned, by the same route she had left, she found Resident 1 lying outside in the dirt, near the door, moaning and crying. LN 1 stated, "When I picked up her head, there was blood... She is confused... She shouldn't go outside unattended." LN 1 stated Resident 1's w/c was right beside her and was in the upright position. On 6/16/16 at 5 p.m., during an interview, the DON stated, "Being outside increases the chances of a fall...The accident would have been avoidable if she hadn't wandered outside. She should not go outside without supervision." The DON stated Resident 1 had a wander guard chair alarm ordered at the time of the fall. On 6/20/16 at 9:50 a.m., during a telephone interview, the Administrator (Admin) 1 stated Resident 1 had a wander guard according to the care plan. Admin 1 stated further investigation was required to determine how Resident 1 had wandered outside unnoticed and unsupervised. On 6/20/16 at 11:59 a.m., during a telephone interview, Admin 1 stated Resident 1 did not have a wander guard at the time of the fall because her w/c was being cleaned that day. Admin 1 stated Resident 1 was in a different (other than her own) w/c the day of the fall, and for some unknown reason, the wander guard had not been transferred to that w/c. On 6/22/16 at 1:45 p.m., Admin 1 stated there was no wander guard on [Resident 1's] w/c the day she fell. On 7/5/16 at 3:10 p.m., during an interview, Certified Nurse Assistant (CNA) 1 stated, "I did not see a wander guard on [Resident 1's] wheel chair the day she fell. If it was on and alarmed I would have heard it. She could open the doors by herself. Before she fell, I watched her and brought her back by the TV. It was about 4 p.m., or a little after, she pushed the door open two to three inches. I saw it, I didn't hear it. There was no alarm." CNA 1 stated she had seen Resident 1 attempt to open the door at least three other times. Resident 1's nurses notes written by LN 1, dated 6/9/16 at 10:49 p.m., indicated, "...found resident outside [facility area] door laying on her back by the bushes, w/c was found next resident, writer assessed resident, blood noted from face and head, resident c/o [complained of] pain to face and head... pressure was applied to laceration to face and head..." Facility document titled, "Housekeeping Work Order # 11982" indicated wheelchair cleaning was conducted on 6/9/16. Resident 1's acute care (hospital) emergency room notes, dated 6/9/16, indicated Resident 1 had an accidental fall which resulted in a forehead laceration and a right shoulder (non-fractured) injury. The emergency room notes indicated, "...presents to Emergency Department complaining of left forehead injury, acute in onset for a couple of hours, continuous, mild to moderate pain... Head is with contusion [bruise] and laceration...Right shoulder: She exhibits decreased range of motion, tenderness, bony tenderness, swelling and pain... A 5 cm (centimeter - a metric measurement), long, c-shaped laceration noted over left forehead area...repaired with... 5 stitches." The facility failed to implement Resident 1's care plan for a wander guard alarm. As a result of this failure, Resident 1 wandered outside unnoticed and unsupervised and sustained a laceration to her forehead requiring stitches and an injury to her right shoulder. The above violation had an immediate direct relationship to Resident 1's health, safety, and security and therefore constitutes a Class "B" Citation. |
| 050000067 |
THOUSAND OAKS HEALTHCARE CENTER |
050011308 |
B |
26-Sep-16 |
7RLM11 |
2925 |
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. Record review on 2/4/16 of a complaint received by the Department indicated an allegation that Resident 1 sustained bruises to both arms as a result of the facility staff rough handling of the patient during care. The complainant stated on 2/2/15, bruises were seen to the right and left wrists of Resident 1, and according to the resident, for the past few months a CNA at the facility had been rough when assisting her (Resident 1) with care in the morning. During an interview on 02/06/15 at 7:45 am, the complainant indicated on 2/2/15, she informed a nurse, the Social Services Director, and the Activity Director of the bruises and the rough handling of Resident 1. Review of Resident 1's record indicated, 94 year old female admitted to the facility on 11/11/13 with diagnoses including stroke and anxiety (excessive worrying). The facility's comprehensive assessment dated 12/04/2014 indicated Resident 1 had no memory problems and required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. During a concurrent observation and interview on 2/6/15 at 8:10 a.m., Resident 1 was observed in bed with purple colored bruise to her right forearm and yellowish-purple colored bruise to her left forearm. Patient 1 indicated a CNA was rough with her and grabbed her arms during care, and pointed to the bruises on both arms. A record review on 02/06/15 of the facility's "Incident Report Form" dated 2/2/15 at 3:20 p.m., indicated Resident 1's "daughter noted skin discoloration to the right and left forearms, checked resident's skin, noted purple color on right forearm and yellow/purple on left forearm. Complain of pain of four out of ten on left forearm only when touched." The facility's Activity Director's Assistant (ADA) indicated, on 2/2/15 Resident 1's daughter notified her of the bruises on the Resident 1's wrists. The ADA stated, "I did not report to anyone since the resident's daughter told me she already reported to Social Services." During an interview on 02/06/15 at 9 am, the facility's Director of Staff Development (DSD) indicated the facility was aware of the allegation that Resident 1 had bruises to both of her arms as a result of a CNA grabbing her arms. The facility was aware of the allegation that Resident 1 had bruises to both of her arms as a result of a CNA grabbing her, but failed to report it to the Department immediately or within 24 hours. |
| 060000041 |
The Pavilion at Sunny Hills |
060010334 |
B |
19-Dec-13 |
6EIF11 |
14771 |
The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to provide medically related social services for residents needing eye appointments, hearing aids, and financial assistance. This involved five different residents (Residents E, D, 13, 4 and 7). Resident E did not receive her eye appointment for 16 months. The resident has glaucoma and has lost the remaining vision in her eyes. Resident D was not assisted with financial matters until her home was in danger of being auctioned off. Resident 13's hearing aids broke, but the facility failed to make arrangements to have them repaired/replaced. As a result, Resident 13 is unable to hear sufficiently to enjoy every day activities. Resident 7 was scheduled for cataract surgery on her left eye in February 2012. When the surgery did not take place, there was no documentation of any follow up found in the clinical record until October 2013. Resident 7 states she is now blind in her left eye. Findings: 1. On 10/10/13 at 0830 hours, an interview was conducted with Resident E. Resident E stated she has glaucoma and has not seen her eye doctor in over a year. She stated she spoke to Social Services (SS) about this over six months ago, but still has not received an eye appointment. She stated she has asked repeatedly to see her own eye doctor due to the loss of sight in her other eye. The resident stated she has lost more of her independence. She stated, last year she could see to dial and answer her phone and provide more of her own care; however, now she cannot answer her phone when friends call her. She stated, due to her friends' ages, the only way they communicate is by telephone and she is losing contact with them. Clinical record review for Resident E was initiated on 10/10/13. Review of the physician's order dated 5/27/12, showed Resident E is receiving Cosopt eye drops daily for glaucoma. Review of the Optometric note dated 5/14/13, showed the physician documented the resident was not provided an eye examination due to the resident wanting to be seen by her own eye physician. Review of the Interdisciplinary Team (IDT) quarterly SS note dated 6/18/13, showed Resident E wants participate in her own care, but she now needs more assistance than in the past. However, there was no documentation regarding the need to schedule an eye appointment. Further review showed the resident did not have any further quarterly SS notes. On 10/16/13 at 1100 hours, during an interview with Social Service Assistant (SSA) 1, who confirmed Resident E's last eye appointment was 7/16/12. 2. Clinical record review for Resident D was initiated on 10/10/13. Review of the Minimum Data Set (MDS) dated 9/14/13, showed Resident D has good cognition. Review of the Social Service Evaluation Quarterly dated 6/27/13, showed Resident D is alert and oriented and capable of making decisions, and doing well. Further review showed no documentation regarding any financial issues or financial assistance being provided to the resident. Review of the Social Service Progress Note dated 8/14/13, showed Resident D made a call to the Social Security office and received notice her income was stopped due to her current stay at the facility. According to the note, Resident D was upset about this situation.Review of the Social Service Progress Note dated 9/11/13, showed Resident D remained upset about her financial situation. Resident D was crying and expressed thoughts of dying. On 10/10/13 at 0800 hours, an interview with Resident D was initiated. Resident D stated she was admitted to the facility in March 2013. The resident stated she has cerebral palsy and has not been able to work. She stated when her parents passed away they left her a mobile home, which is where she resided all her life. The resident stated she received supplement security income (SSI) which paid for the mobile home space rent and allowed her to live independently. In March 2013, she had fallen at home and was transferred to the facility temporarily. Resident D stated the plan is for her to go home or to a lower level of care. According to Resident D, in early September 2013, she received a notice her mobile home would be auctioned off to pay for overdue rental space. Resident D stated she was not aware her SSI payments had been stopped until August 2013. She was still sending checks to the mobile home park but her bank accounts were overdrawn, causing the bank to close her accounts. The resident stated she was not aware of her money issues until it was too late, and she was not made aware by the facility of where her money was going. An interview with SSA 1 was initiated on 10/16/13 at 1100 hours. SSA 1 confirmed Resident D's story. SSA 1 stated he has worked at the facility a few months and has been made aware of Resident D's problems. SSA 1 stated he has been working to assist Resident D with her financial issues and the auction of her home. SSA 1 was asked if Resident D had been aware of the money issue prior to August. SSA 1 stated the resident appeared not to be aware where her money was going prior to August. 3. Review of the facility's P&P titled Social Services dated May 2002 showed social services will assist residents in obtaining needed clinical and support services. The Social Services or designee maintains a list of individuals requiring dental/denture care, vision care, hearing services. On 10/10/13 at 0915 hours, an interview was attempted with Resident 13. However, Resident 13 stated, "I cannot hear you; let me just get my hearing aid in my drawer." When the resident placed the hearing aid in the right ear, it was a Bluetooth (wireless earpiece used for hands free mobile telephone) not a hearing aid. When Resident 13 was asked where the real hearing aid was, Resident 13 stated, "It was broken since last year, and they (facility staff) gave this device to me six months ago." Resident 13 stated she told the nurses and social services she really needs a replacement for her hearing aids because she cannot hear and does not know how to read lips. She stated social services staff told her they cannot replace it right now because of an insurance problem. When asked how she feels when she is talking to people but cannot hear the conversation, she stated "I cannot communicate very well because I cannot hear them, especially during our resident council meetings.? She stated other residents ask her for her opinion and she has to answer them back with, ?yes,? because she cannot hear or understand what they are saying. She stated she really needs her hearing aid to function to participate in daily life.Review of Resident 13's clinical record on 10/10/13, showed she was admitted to the facility on 12/29/11. Review of Resident 13's MDS shows she is alert, oriented and without cognitive problems.A physician's order dated 5/21/12, showed the resident is to have her right hearing aid in place daily at 0900 hours and off at 2100 hours; and, when not in use, keep them at the nurses? station.Review of a hearing aid center report dated 1/12/12, showed hearing receiver replaced and faceplate changed, and it was received by the facility. Review of SSA progress notes and IDT notes since 2012 to present showed in all documentation the resident did not need referrals or outside resources at this time. No documentation was found regarding a broken or replaced hearing aid. During an interview conducted with Licensed Vocation Nurse (LVN) 5 on 10/10/13 at 0945 hours, LVN 5 was asked about the hearing aid. She stated it was with the resident. LVN 5 was asked to locate the hearing aid, but she could not find it. LVN 5 verified the above findings. LVN 5 stated she will follow up with the SSA. During an interview conducted with SSA 1 on 10/11/13 at 1500 hours, SSA 1 was asked about the hearing aid. SSA 1 verified the above findings. He stated, "I just started here two months ago. As far as I know, they provided the resident a device (Bluetooth) or amplifier in the meantime, but I just got an approval from the insurance (medi-Cal) for both a hearing test and hearing aids today." 4. During an interview with Resident 4 on 10/8/13 at 1120 hours, Resident 4 stated her hearing aids have been broken for at least two months and no one has told her anything about what is going on with her hearing aids. She stated she still attends meetings and activities to get out of her room and see other people, but she cannot hear what is being said, so she does not know what is going on a lot of time. Resident 4 stated this really bothers her. She stated she cannot talk with friends or enjoy activities without being able to hear. Clinical Record review was initiated on 10/8/13, for Resident 4. Review of the Hearing Evaluation Sheet shows results of an audiometry exam (hearing test to evaluate a person's ability to hear) performed on 10/29/12. Under remarks, the examiner documented "AU - severe SNHL" (severe hearing loss in both ears). The form also showed Resident 4 wears hearing aids in both ears. Review of Resident 4's Medication Administration Records (MAR) for June, July, August, and September 2013 showed the hearing aids were no longer being used. As of 6/26/13, staff had documented "0" or "broken.? Review of all of Resident 4's Social Services Progress Notes showed no mention of Resident 4's broken hearing aids needing repair. Review of the Nurses' Progress Notes dated 6/26/13 through 10/8/13, showed no documentation of, or communication to social services regarding, the broken hearing aids. On 10/8/13 at 1145 hours, during an interview with SSA 2, she stated she began employment with the facility in May, 2013. She stated began working on the unit Resident 4 resided on in July 2013. SSA 1 stated she is aware of Resident 4's broken hearing aids, and is currently in possession of them. She stated she is unsure how long they have been broken, or when she was made aware they needed repair. She stated she normally makes a notation on the Social Services Progress Notes the same day she is informed of a problem. She stated there is no system in place to track residents? devices needing repair. She acknowledged it is her responsibility to make sure the appropriate repair services are called, and to have the devices delivered for servicing. SSA 1 knew the repair service company?s name and a contact person to call. However, she could not remember the date when she notified the repair company. When asked, she was not able to explain why Resident 4?s hearing aids have not been sent for repair. 5. Clinical record review for Resident 7 was initiated on 10/10/13. Resident 7 was admitted to the facility on 7/27/08, with a diagnoses including diabetes and end stage renal disease (failure of the kidneys to rid the body of waste products through the urine) requiring hemodialysis (use of a machine to remove waste products from the blood when the kidneys no longer work). During an interview with Resident 7 on 10/10/13 at 0820 hours, and on 10/13/13 at 1210 hours, Resident 7 stated she had cataract surgery to one eye before being admitted to the facility. She stated she was told at the time of that surgery she would need cataract surgery on her other eye. Resident 7 stated she has no vision in her other eye now. She stated social service staff told her she has an appointment to see the eye doctor in January, 2014. A physician's order dated 10/16/13 at 0915 hours, showed authorization was received on 10/14/13, to see an Ophthalmologist for an eye exam for visual disturbances.Review of the social services notes found no other documented information regarding Resident 7 having an ophthalmology appointment since her admission.During an interview with SSA 2 on 10/16/13 at 0920 hours, SSA 2 was asked to show any documentation of previous ophthalmology consults for Resident 7. The SSA found an IDT note dated 4/19/12, showing a section for social services to address the resident's need for hearing, vision, and dental; however, all areas were marked "no." The comments section shows "ophthalmology recommendation by physician but (resident) refuses ophthalmology consult will revisit in three months..."On 10/16/13 at approximately 0920 hours, Resident 7 was in the hallway near the nurses' station (at the time of this record review). Resident 7 was asked if she refused to go to the Ophthalmologist last year. Resident 7 stated she had never refused to be seen by the Ophthalmologist. Resident 7 stated she is now blind in her left eye. Review of a quarterly social service evaluation dated 6/30/12, shows, under sensory concerns, the resident has some vision problems, is able to read large print only, has eyeglasses for reading, and social services will refer resident for any ancillary services. When asked if there is any documentation to show a referral had been made for an ophthalmology evaluation after 6/30/12, the SSA stated she would look in the old clinical record. On 10/16/13 at 1100 hours, the SSA stated she called the ophthalmologist's office and had them fax a copy of their appointment calendar showing Resident 7 had canceled her scheduled cataract surgery on 2/21/12. Review of the faxed material showed Resident 7 was seen by the ophthalmologist on 1/9/12, for a preoperative appointment scheduled for 2/14/12. However, another note identified Resident 7 was a "no show" for the scheduled surgery on 2/21/12. Someone documented the resident canceled. When asked why there was no social service follow-up after the surgery was canceled, and why there was no further discussion of an ophthalmology evaluation found in Resident 7?s clinical record (after 4/9/12), the SSA was unable to explain. The SSA stated Resident 7 now has an appointment for an ophthalmology evaluation on 1/13/14. When asked what day of the week this appointment is scheduled, the SSA checked the calendar and found it was scheduled for a Monday. When reminded Resident 7 receives routine dialysis on Monday, Wednesday and Friday, the SSA changed the appointment to a Tuesday. When reminded Resident 7 will not miss bingo, the SSA stated she will discuss the appointment day and time with Resident 7 before finalizing the appointment. The facility?s failure to provide medically related social services resulted in two residents losing their eyesight, two residents with the inability to hear and communicate and participate in daily activities effectively due to prolonged periods with no working hearing aids, causing a loss of socialization, and one resident almost having her home auctioned off. These failures have a direct and immediate relationship to the health, safety or welfare of the residents. |
| 060000041 |
The Pavilion at Sunny Hills |
060010335 |
B |
19-Dec-13 |
6EIF11 |
13121 |
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 promptly and thoroughly investigate allegations of abuse for Resident Q and Resident 13. Resident Q reported an allegation of abuse on 5/24/13, involving Certified Nursing Assistant (CNA) 16. However, administration failed to ensure an investigation was conducted regarding the allegation. On 10/25/13, Resident Q and her family member again reported the allegation of abuse from May 2013, to Social Service Assistant (SSA) 1. This time an investigation was done, however, the facility did not interview staff members or other residents as part of their investigation.On 8/31/13 and 10/16/13, Resident 13 reported allegations of abuse involving CNA 16. The allegation of abuse on 8/31/13, was not investigated. In addition, the allegation on 10/16/13 was not thoroughly investigated; the facility did not interview any other residents to determine if there may have been any other allegations of abuse against CNA 16. As a result, CNA 16 continued to work in the facility.On 11/21/13, during an investigation conducted by the California Department of Public Health (CDPH), Licensing & Certification, a third resident (Resident D) verbalized allegations of repeated sexual abuse by CNA 16. Findings: According to the facility's policy and procedure (P&P) titled California Mandatory Reporting dated 7/02, employees are mandated reporters in California, per California law and are required to report all abuse, sexual and physical assaults. An interview with Administrator 3 was conducted on 11/13/13 at 1100 hours. He stated he received an allegation of abuse from Resident Q against CNA 16 on 10/29/13. The Administrator was asked to provide all evidence from the investigation into the allegation of abuse regarding Resident Q. The Administrator stated he asked SSA 1 to take Resident Q's statement. He stated Resident Q was interviewed and CNA 16?s employment was terminated on or about 10/24/13. When asked if he interviewed any other residents or staff members, the Administrator stated, ?No.? Clinical record review for Resident Q was initiated on 11/13/13. Review of the Minimum Data Sets (MDS, an assessment tool) dated 8/23/13 and 2/20/13, showed the resident is alert, oriented and can communicate her needs. Review of a Social Service Progress Note dated 10/29/13, showed SSA 1 interviewed Resident Q and her family member on 10/29/13, regarding the resident?s allegation against CNA 16. According to the Social Service Note, Resident Q reported in May or June, CNA 16 began to massage her back and proceeded to give her a full body massage. The report showed Resident Q told SSA 1 the CNA got too close to her private area and she felt uncomfortable. Resident Q requested she only receive care from female CNAs. On 11/13/13 at 1515 hours, an interview with Resident Q was initiated. Resident Q stated she was admitted to the facility early in the year, and resided on the first floor for about two months. She stated she was then transferred to the second floor. She stated CNA 16 was assigned to care for her on 5/24/13. She stated, in the middle of the night (on 5/24/13), she had soiled her clothing and CNA 16 helped her to the bathroom, removed her clothing and then put her into bed naked. She stated her back was hurting and CNA 16 began to massage her back, but then began to massage her front. She said that is when CNA 16 went too low towards her private region and she became very uncomfortable. Resident Q was asked how she remembered when the incident occurred. She stated she wrote the date and the name of the CNA in her journal. She stated she also documented the name of the licensed nurse (Assistant Director of Nurses - ADON 2) who she reported the incident to. Resident Q retrieved her journal and showed the entries she had made in her journal verifying CNA 16?s and ADON 2?s names and the date of the incident. Resident Q stated she told her family member about what happened the next day. The resident was asked if anyone at the facility investigated or asked her any questions about what happened after that. She stated, no. She stated she finally told the Director of Nurses (DON) she did not want any male CNAs caring for her again. An interview was conducted with ADON 2 on 11/13/13 at 1545 hours. ADON 2 stated she was informed of the incident by Resident Q in May and reported it to Administrator 1. ADON 2 stated she was not aware of any investigation into the incident. On 11/13/13 at 1630 hours, an interview with Resident Q's family member was conducted. The family member stated Resident Q called her and told her what happened with CNA 16 in May 2013. The family member stated she called the Administrator?s office, but Administrator 1 did not answer the phone. The family member stated she left a long message about the incident for the Administrator, but never heard back from her. When asked if the family member knew of any investigation or if the resident was interviewed by facility staff regarding her grievance against CNA 16, the family member stated, no; no one interviewed her or the resident.Review of CNA 16?s Time Detail report verified he had worked on 5/24/13. b. Clinical record review for Resident 13 was initiated on 10/15/13. The MDS dated 9/24/13, showed the resident is cognitively intact. Further review showed the resident has no hallucinations (false perception that appears to be real) or delusions (false belief held despite strong evidence against it). Review of the nurse's note dated 8/31/13 at 0215 hours, showed the resident reported to the nurse a CNA went in her room, hit her legs while the resident was in bed, and left the room. The note further showed the CNA assigned to Resident 13 was changed and the incident was reported to Administrator 1. Review of the Physician's Progress Note dated 9/3/13, showed the resident falsely accused a staff member of touching and hitting her legs. During an interview with Administrator 1 on 10/15/13 at 1500 hours, she was asked if she has any investigations for Resident 13. She replied, no. An interview was conducted with Licensed Vocation Nurse (LVN) 8 on 10/17/13. LVN 8 was asked their policy regarding allegations of abuse. He stated they have to notify the Administrator and the Ombudsman. He further stated an allegation of abuse occurred two months ago involving Resident 13 and CNA 16. The resident had reported CNA 16 had touched her and walked out of the room. He stated he called Administrator 1 to report the incident and was informed to document the incident, initiate behavior monitoring for Resident 13, and Administrator 1 would follow-up in the morning. LVN 8 was asked what happened to CNA 16. He stated, he reassigned the CNA to another area of the facility. LVN 8 was informed the allegation was not investigated. He stated he thought Administrator 1 conducted an investigation because the staff completed their statements. Additional clinical record review showed psychiatrist's notes dated 9/21/13 and 10/9/13, which identified Resident 13 had no hallucinations or delusions. During an interview with ADON 2 on 10/17/13, she was asked their policy on allegations of abuse. She stated, if the allegation is against a staff member, the staff member has to be sent home. On 10/17/13 at 1415 hours, an interview was conducted with Resident 13. She stated there was a man (CNA 16) who entered her room, touched her shoulder and caressed her legs. She was asked if she told anyone. She stated it happened several times and she had reported him before. She stated they reassigned him to another location in the facility. She was asked if it happened again. She replied, yes, and stated she was determined to report him. She further stated, just this week, he came in my room again and touched my shoulder, but this time she had a reacher (a tool used to pick up things) and I hit the man on the head. She stated that man is a CNA and stated CNA 16's name. She stated CNA 16 works the 11-7 shift. When asked what day of the week it happened. She stated if today is Thursday, then Tuesday night. She was asked if she reported the incident. She stated she reported it to ADON 2 and SSA 1. She further stated SSA 1 wanted her to move to another room, but she refused. She stated she is not the criminal. She stated CNA 16 was reassigned to another location. Review of the CNA staffing schedule and assignments for 10/15/13 (Tuesday) 11-7 shift showed CNA 16 was working that night and assigned to rooms on the same hallway where Resident 13's room is located. On 10/17/13 at 1540 hours, an interview was initiated with SSA 1. The SSA confirmed Resident 13 had reported being inappropriately touched by CNA 16 on 10/15/13. He stated they called CNA 16 in for questioning. SSA 1 was asked to provide the facility's investigation. He stated the Corporate Consultant Nurse asked him to interview Resident 13 again and asked if she felt violated or unsafe. SSA 1 stated the resident did not feel violated or unsafe, so the facility did not submit a report to the CDPH or the Ombudsman. When he was asked to provide the facility's investigation, he stated he will get it from the Corporate Consultant Nurse. On 10/17/13 at 1615 hours, SSA 1 provided copies of statements from CNA 16 and a brief statement from CNA 17 showing she was assigned to Resident 13. SSA 1's interview with Resident 13 showed Resident 13 stated a CNA went into her room and touched her, but she hit the CNA on the head. The interview did not show if the resident was asked if any other incidents occurred involving CNA 16. There was no documented evidence the facility interviewed the charge nurse, RN supervisor, other CNAs or other residents.Review of the Corporate Consultant Nurse?s follow-up notification letter dated 10/17/13, showed the nurse confirmed CNA 16 was working on 10/15/13, but was not assigned to care for Resident 13. The letter showed Resident 13 stated she had hit someone who came into her room with her reacher after she was inappropriately touched, but she could not confirm who it was as it was dark in her room. The resident then got up out of bed and saw CNA 16 walking down the hall holding the back of his head. The Corporate Consultant Nurse identified he had examined CNA 16?s head on 10/17/13, but saw no evidence of an injury to support Resident 13?s statement. The report showed he called the resident?s family member and the resident?s psychiatrist to report what happened. The letter further showed CNA 16 would be allowed to return to work. The letter did not show any interviews were conducted with any other residents.During an interview with an anonymous staff member on 10/18/13 at 1000 hours, the staff member stated they were instructed by the Corporate Consultant Nurse not to report or document Resident 13's allegation of abuse on 10/16/13. CNA 16 last day of employment at the facility was 10/28/13. c. On 11/14/13 at 0930 hours, an interview was conducted with Resident D. Resident D was asked if any facility staff member has ever done anything inappropriate or made her uncomfortable while providing care to her. Resident D stated, yes, a male CNA (CNA 16) on the night shift had touched her vaginal area too much and too deep while changing her incontinence briefs. She stated it happened two or three times a few months ago. Resident D stated she was shocked by what happened and did not know what to do. She said she was too embarrassed to tell anyone.Clinical record review for Resident D was initiated on 11/14/13. The MDS dated 9/14/13, showed she was alert, oriented and has no cognitive problems. The resident wears an incontinence brief at night and requires staff?s assistance to change it.On 12/3/13, the facility reported a Manager from CDPH Investigation Section was at the facility and interviewed Resident D regarding her allegations of abuse by CNA 16. Resident D provided specific details as to what CNA 16 did to her. She stated, while he was changing her incontinence brief and cleaning her, CNA 16 put his finger into her vagina. She said it happened on three separate occasions within a one week period. When asked if he said or did anything while he was touching her, she stated, ?He had a smile on his face and looked at me while it was happening.? She stated she had no idea what was going on and was in shock, ?I didn?t know what to do.? She stated, on the third occasion, she rolled over so he would stop. She stated he said to her ?You like my work?? When the Manager asked if she had reported it to anyone, she replied, ?I was so embarrassed and didn?t know what really happened.? The resident revealed she had never been sexually active and is a virgin.The lack of investigation into the allegations of abuse against CNA 16 allowed him to continue working with vulnerable female residents. As a result, this has a direct relationship to the health, safety or security of residents. |
| 060000159 |
TOWN AND COUNTRY MANOR |
060011798 |
B |
27-Oct-15 |
3GDN11 |
6802 |
F246: A resident has the right to reside and receive services in the facility with reasonable accommodations of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered. Based on observation, interview, and clinical record review, the facility failed to accommodate the individual needs for Resident 4 timely. The facility failed to provide a bed long enough to accommodate Resident 4's height. This failure resulted in Resident 4 developing a Stage III (full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed) pressure ulcer to the coccyx area (tailbone) due to his inability to properly reposition himself in the short bed. It also caused the resident to be uncomfortable and unable to roll and sleep on his sides.Findings:During an initial tour on 9/14/15 at 0851 hours, with Licensed Vocational Nurse (LVN) 2, Resident 4 was observed in a bed with his foot pressing on the foot board. Resident 4 complained his bed was too short for his height. This finding was verified with LVN 2. LVN 2 stated she would check the clinical record if there had been a change of the bed since Resident 4 was admitted.Clinical record review for Resident 4 was initiated on 9/14/15. Resident 4 was admitted to the facility on 8/21/15, with diagnoses including osteoarthritis (a disease of the joints) with post total knee arthroplasty (surgical replacement of a joint).Review of the Minimum Data Set (assessment too) dated 8/28/15, showed Resident 4 was 76 inches (6'4") tall and weighed 236 pounds. The resident was cognitively intact and required extensive assistance for transfers and ambulation. Review of the Initial Body Assessment dated 8/21/15, showed Resident 4 had no pressure ulcers. However, review of the Skin Integrity Sheet dated 9/8/15, showed Resident 4 developed a Stage II (partial thickness loss of the skin presenting as a shallow open ulcer with a red pink wound bed) pressure ulcer on his coccyx area.Review of the Skin Integrity Sheet dated 9/14/15, showed a Stage III pressure ulcer located at Resident 4's coccyx area measured 2 cm long x 2 cm wide x 0.1 cm deep. Review of the physician's order dated 9/14/15, showed a treatment order for a Stage III pressure ulcer on Resident 4's coccyx.On 9/14/15 at 0851 hours, an interview was conducted with Resident 4. Resident 4 stated the short bed was the only complaint since he was admitted to the facility. He stated he was 6'5" tall. He stated he normally slept on his sides at home, but here he stayed "mostly flat." Resident 4 was asked if he told the facility about his concern. He stated he told the staff and his physician. He stated the facility accommodated him by removing the foot board so he could fit in the bed; however, when the footboard was removed, nothing supported his feet. Resident 4 stated he still stayed in the short bed. Resident 4 stated he developed a pressure ulcer in the facility. Resident 4 was asked if he was instructed to roll on his sides to keep pressure off of his back. He stated he was instructed to reposition himself on his sides most of the time while in bed; however, when he rolled on his sides, his legs "crinkled." Resident 4 stated he would rather reposition himself flat because the bed was too short for him.A follow-up interview with Resident 4 was conducted on 9/14/15 at 1242 hours. Resident 4 stated he was glad he received a longer bed on 9/14/15. He stated he wished the facility could have given it to him 10 days ago.On 9/14/15 at 1505 hours, an interview and concurrent clinical record review was conducted with Physical Therapist (PT) 1. PT 1 stated there was no documentation of Resident 4's bed being too short during the physical therapy evaluation. On 9/14/15 at 1530 hours, an interview was conducted with the SSD. The SSD was asked if she was aware of Resident 4's concern with the short bed. The SSD stated she met the resident on 9/10/15, and was notified by the resident of his concern. The SSD stated she told Resident 4 the facility had longer beds available; however, when she asked the housekeeping staff and Administrator for the longer bed for Resident 4, she was informed there was no available longer bed at the moment for Resident 4. A follow-up interview with Resident 4 and his family member was conducted on 9/15/15 at 1025 hours. Resident 4 stated he did a lot of scooting back up because the bed was too short. He stated he kept pushing himself up in the bed because his feet were sliding down and pressing on the foot board. Resident 4's family member also stated the extra friction added up and the scooting up added more pressure to his back. A wound dressing observation was conducted on 9/15/15 at 1050 hours, with LVN 5. The wound located on Resident 4's coccyx was observed with whitish to yellowish discharge and with slough (dead tissue). LVN 5 was asked how Resident 4 developed the Stage II pressure ulcer. She stated it was from moisture. She stated she did not receive any reports if the resident refused to be repositioned and the resident was always compliant. Resident 4 was observed with an incision scar on his upper back. Resident 4 stated he had a back surgery in 1985 and would not be able to stay flat in a sitting position while in bed. Resident 4 stated he would like to sleep on his sides with his back straight while he was laying in his bed. On 9/15/15 at 1250 hours, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated Resident 4 was continent. She stated Resident 4 was able to roll himself from side to side while in bed, he required two persons' assistance to go to the bathroom. CNA 3 stated Resident 4 complained to her "a while ago" that "the bed is too short for him." CNA 3 stated she filled out a work order sheet for the housekeeping staff. CNA 3 stated the housekeeping staff changed the resident's bed; however, the resident's feet still touched the footboard. On 9/15/15 at 1255 hours, an interview was conducted with the Housekeeping Supervisor. The Housekeeping Supervisor stated the housekeeping staff was the one in charge of providing the beds for the residents. He stated the facility had 6 longer beds (86 inches) available in the facility. He received the request for Resident 4's longer bed; however, all the longer beds were in use at that time. The Housekeeping Supervisor stated the facility could have accommodated the resident's need by switching his bed with another resident who had a longer bed. The facility could have checked the other longer beds being used by other residents who did not need a longer bed and switched beds to accommodate Resident 4. These failures have a direct and immediate relationship to the health, safety or security of patients. |
| 060000041 |
The Pavilion at Sunny Hills |
060013455 |
A |
28-Aug-17 |
S05V11 |
29956 |
Based on the findings during the Abbreviated Survey a Class A state citation was written at F309 (483.10, 483.24 and 483.25)
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 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.
?483.10 Resident rights
(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);
On 12/2/16, an unannounced visit was conducted at the facility to initiate an investigation regarding Resident 2 who sustained an unwitnessed fall.
Resident 2 had recently undergone recent hip surgery and was recovering at the facility. Resident 2 was able to make her needs known and required assistance to walk with a walker, but was alert and verbally responsive. On 11/28/16 at 0210 hours, Resident 2 was found lying on the floor on her left side near the bathroom door.
Based on observation, interview and record review, the facility failed to identify and inform the physician of a decline in the neurological condition after Resident 2 sustained a fall.
The facility failed to ensure the abductor pillow (a cushioned wedge placed between the patient's legs to maintain position and prevent dislocation of the hip joint) was applied as ordered for Resident 2.
* Resident 2 sustained an unwitnessed fall on 11/28/16 at approximately 0210 hours, and a change in her neurological status at 0755 hours. Resident 2's physician was not informed of this change. Resident 2 showed a further decline and was transferred to the acute care hospital emergency department via paramedics. A CT scan (Computed Tomography - specialized x-ray providing more detailed images than a plain x-ray) showed Resident 2 had a large right-sided subdural hemorrhage (a collection of blood in the brain) with a midline shift (one half of the brain is pushed across the middle line of the brain cavity into the space occupied by the other half of the brain , usually caused by swelling in one side of the brain) and obstructive hydrocephalus (blockage of the flow of the clear fluid found in the brain and spinal cord through its normal pathways preventing drainage of the fluid and causing an abnormal buildup of fluid) with an enlarged left temporal horn. Resident 2 expired 48 hours later.
* Resident 2 had a physician's order to apply an abductor pillow at all times while in bed, which was not in place during the night shift on 11/27/16. This had the potential for the resident to sustain an injury such as a dislocation of the resident's recently surgical repair of a fractured hip joint.
Findings:
Review of Resident 2's closed medical record was initiated on 12/6/16. Resident 2 was admitted to the facility on XXXXXXX16, with diagnoses including dementia and a recent fall (prior to admission to the facility), resulting in a fracture of the right hip and requiring a surgical repair.
Review of her Minimum Data Set (assessment tool) showed Resident 2 was alert with confusion at times. She required assistance to ambulate with a front wheel walker.
a. Review of Resident 2's Progress Notes (the licensed nurses' notes) showed the following entries:
- On 11/10/16, staff documented on admission, Resident 2 was alert, verbally responsive, and able to make simple needs known with episodes of forgetfulness secondary to dementia.
- On 11/27/16 at 1924 hours, Resident 2 was lying in bed awake, alert, and verbally responsive; and the resident's call light was within her reach.
- On 11/28/17 at 0322 hours, Resident 2 was heard at 0210 hours, was found lying on the floor in her room near the bathroom.
- On 11/28/16 at 0238 hours, hydrocodone-acetaminophen (a narcotic pain reliever) 5-325 mg (milligrams) was administered to the resident for the right leg pain.
Review of Resident 2's Situation Background Assessment Recommendation Communication (SBAR) for Changes in Condition Assessment Summary form dated 11/28/16 at 0322 hours, showed Resident 2 had an unwitnessed fall. According to the documentation Resident 2 was alert and responsive able to answer simple questions after the fall incident with episodes of confusion and forgetfulness. Resident 2 was started on neuro checks (an exam of the resident's level of consciousness, movement, hand grasps, left and right pupil size and reaction, speech, vital signs [blood pressure, pulse, respiratory rate, and temperature], and pain level).
The resident's vital signs showed her blood pressure was 143/69, her pulse was 101 and her heart rate was 20.
Review of Resident 2's Neurological Flow Sheet form dated 11/28/16, showed the instructions for the licensed nurses to complete this form for any unwitnessed falls for 72 hours following a fall and inform the attending physician if there was a deviation from the resident's normal status.
Review of the Neurological Flow Sheet showed staff were to assess a resident every 15 minutes for 1 hour, every 30 minutes for 1 hour, every hour for 4 hours and then every 4 hours for 24 hours.
Review of Resident 2's Neurological Flow Sheet dated 11/28/16 showed the following:
- At 0210, 0225, 0240, 0255, 0325, 0355, 0455, 0555, and 0655 hours:
Level of Consciousness = "1" (fully conscious - awake, aware, oriented)
Movement = "1" (all four extremities)
Hand Grasps = 1 (equal and strong)
Pupil Reaction left/right = 1/1 (brisk)
Speech = "1" (clear)
- At 0755 hours, Resident 2's neurological exam results showed the following decline:
Level of Consciousness = "3" (obtund - very drowsy, responds to touch stimuli)
Speech = left blank
- At 1155 hours, Resident 2's neurological exam showed further decline:
Level of Consciousness = "4" (stupor - responds only to painful stimuli)
Movement = "7" (no movement/unusual movement)
Hand Grasps = "4" (none)
Pupil Reaction = "3" (fixed)
Speech marked = "N/A"
Further review of Resident 2's Progress Notes (the licensed nurses' notes) dated 11/28/16, showed the following:
- At 0730 hours, Resident 2 was sleeping comfortably with no facial grimacing indicating pain/discomfort.
- At 0743 hours, LVN (Licensed Vocational Nurse ) 6 documented at 0342 hours, the x-ray technician arrived at 0551 hours, the x-ray results were received; at 0600 hours, Resident 2's physician was informed of the x-ray results [the resident's right hip was x-rayed].
- At 0750 hours, Resident 2's daughter was at the bedside assisting the resident with her breakfast. The resident was having a hard time keeping her eyes open.
- At 0800 hours, according to the CNA (Certified Nursing Assistant) Resident 2 consumed 30% of her breakfast.
- At 0805 hours, CNA offered the resident a shower and the resident's daughter suggested to let Resident 2 to rest and nap.
- At 0950 hours, the licensed nurse tried to administer Resident 2's medication; however, Resident 2 was asleep; the resident's two family member agreed to give the resident's medications when the resident awakened.
- At 1054 hours, LVN 5 spoke with Resident 2's physician and reported the results of the x-ray received from the resident's orthopedic surgeon's office. There was no documented evidence the physician was informed of the resident's decline in the neurological condition starting at 0755 hours on 11/28/16.
- At 1058 hours, Resident 2 was asleep, responsive to verbal and tactile stimuli with no facial grimacing to indicate any discomfort. Again, there was no documented evidence the physician was informed of the resident's decline in the neurological condition of a fall at 0755 hours and a further decline at 1115 hour on 11/28/16.
- At 1239 hours, CNA 1 notified LVN 5 at approximately 1200 hours Resident 2 was lethargic and the family was concerned. Resident was in bed asleep and not responding to verbal or tactile stimuli. Resident moved both arms in response to a sternal rub. Resident 2 was not able to follow commands or open her eyes, snoring, and not waking up. RN (Registered Nurse) 1 was called to the room and spoke with Resident 2's family who wanted to wait for the resident's attending physician to evaluate the resident. RN 1 and LVN 5 recommended transferring Resident 2 to the acute care hospital emergency department for evaluation. The family members agreed to the transfer. Staff called 911 and the paramedics arrived at 1210 hours. At 1220 hours, Resident 2's attending physician was called and a message was left for the physician. The paramedics transported Resident 2 to the emergency department at 1224 hours.
There was no documentation in Resident 2's medical record to show the physician was informed of the resident's neurological changes documented by LVN 1 on 11/28/16, starting at 0755 hours.
On 12/6/16 at 1415, an interview was conducted with CNA 1. CNA 1 stated Resident 2 was normally very alert and able to make her needs known. The resident required limited assistance of one person to walk to the bathroom using a walker. CNA 1 was asked to describe the events of 11/28/16, from the beginning of the day shift until the resident was transferred to the hospital.
CNA 1 stated Resident 2 was sleeping during his first rounds at approximately 0720 hours. At approximately 0740 hours, CNA 1 delivered the resident's breakfast tray; the resident was still sleeping and the resident's daughter had set up the tray. When he picked up the resident's tray after approximately 30 minutes, the resident was asleep. There was approximately 30% of the breakfast consumed; however, CNA 1 stated the daughter later told him the resident had eaten one half a slice of toast, and the daughter had eaten the rest of the 30%. The resident usually ate 70-100%; he and the daughter assumed it was because the resident was tired. CNA 1 stated at 1040 hours when he went to offer Resident 2 a shower the resident was asleep and the resident's daughter asked him to wait until tomorrow. CNA 1 stated at approximately 1150 hours, one of the resident's family members asked him to call a licensed nurse. CNA 1 told LVN 5 who went to Resident 2's room. CNA 1 stated he did not follow the LVN into the resident's room. CNA 1 stated he had not seen Resident 2 awake at all since he came on duty that day.
On 12/6/16 at 1515 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 2 was usually awake, alert, oriented, and able to make her needs known without confusion. LVN 1 was asked to describe the events of 11/28/16, from the beginning of the shift until the resident was transferred to the hospital.
LVN 1 stated she saw Resident 2 on 11/28/16 prior to 0800 hours and stated Resident 2 was sleeping. LVN 1 stated she performed a neurological exam before 0800 hours. LVN 1 stated the Resident 2's pupils reacted equally and quickly; the resident did not respond or grasp at all when LVN 1 had asked the resident to squeeze two of her fingers and did not move her legs at all when asked. LVN 1 stated CNA 1 took the resident's vital signs and they were normal.
LVN 1 stated at 0945 hours, she went to administer Resident 2 her medications but was unable to do so because Resident 2 had a hard time waking up. LVN 1 stated the resident could not keep her eyes open which was usually not the case. LVN 1 stated she thought maybe the resident was sleeping due to the events (fall) during the night and the pain pill the resident had taken (at 0238 hours).
LVN 1 saw the resident again just before 1100 hours and she was asleep. LVN 1 held Resident 2's hands, and the resident moved but did not open her eyes or speak.
LVN 1 stated at approximately 1200 hours, while she was on her lunch break, she heard a "code blue" announced for Resident 2's room. When LVN 1 arrived to the room, the resident had a pulse and was breathing. However, the staff could not arouse the resident. LVN 1 stated when a sternal rub (rubbing the knuckles across the breast bone as a form of painful stimuli) was performed on the resident, there was slight movement of her legs and shoulders; however, the resident did not awaken. LVN 1 stated she thought it was from the dose of Norco (generic for hydrocodone-acetaminophen 5-325 mg) the resident had received after the fall. LVN 1 stated she had not observed Resident 2 have this type of reaction after the pain medication administration in the past. LVN 1 stated the 911 was called and the paramedics arrived at approximately 1210 hours.
When LVN 1 was asked to explain the discrepancy between her documented description of the neurological exam noted above (Resident 2 had no hand grasp and did not move her legs) and what was documented on the Neurological Flow Sheet (hand grasps were equal and strong, moved all four extremities) at 0755 hours, LVN 1 stated she did not have an explanation.
On 12/6/16 at 1540 hours, an interview was conducted with RN 1. RN 1 was asked to describe the events of 11/28/16. RN 1 stated Resident 2 was a short-term resident and admitted to the facility for rehabilitation following surgery for a hip fracture. RN 1 stated RN 2 reported Resident 2 had fallen during the night shift. Resident 2 had been found on the floor, was awake, alert, oriented, and stated she did not hit her head. The night shift nurses had recommended the resident be transferred to the emergency department due to her recent history of surgical hip fracture repair and pain. However, Resident 2's physician did not order a transfer and ordered for a STAT (performed immediately) x-ray.
RN 1 stated LVN 5 asked her to assess Resident 2 on 11/28/16 at approximately 1200 hours, secondary to a change in the resident's condition. RN 1 went to Resident 2's room. The family was at the bedside reported the resident would not wake up. The resident's vital signs were normal and showing no signs of distress; she just would not wake up. LVN 5 performed a sternal rub and Resident 2 shrugged; however, she did not open her eyes or move any other body parts. RN 1 stated the family initially wanted to wait for Resident 2's physician. RN 1 recommended transferring the resident to the hospital via 911 and the family agreed. The paramedics arrived at approximately 1215 hours. RN 1 stated she was not informed by the charge nurse or the CNA anything unusual for Resident 2 earlier in the shift.
On 7/20/17 at 0840 hours, a telephone interview was conducted with Resident 2's Family Member 1. Family Member 1 stated the facility had informed her Resident 2 fell on 11/28/16 at approximately 0315 hours. When the family arrived at the facility at approximately 0330 hours, the resident did not look like her usual self; her speech was slurred and she did not answer any questions regarding what had happened. The family member stated the resident fell asleep at approximately 0530 or 0600 hours, after speaking to another family member; it was the last time the resident spoke.
The family member stated at 0800 hours, when they delivered Resident 2's breakfast, the resident was asleep. Family Member 1 attempted to feed the resident; however, the resident was very drowsy and could hardly stay awake. The resident kept chewing on the same bite of toast, and did not consume any other food or fluids from the breakfast tray. The resident slept all morning and when the lunch tray was delivered, she (the family member) asked the nurse to check the resident because she was still asleep. Shortly afterwards, the staff called 911 and the resident was then transferred to the acute hospital emergency department. When asked, Family Member 1 stated she did not recall the nursing staff assessing the resident's eyes, hand grasps, or movement during either the night or day shifts.
On 7/20/17 at 0941 hours, a telephone interview was conducted with Family Member 2. Family Member 2 stated the family arrived at 0330 hours on 11/28/16, after being informed the resident had fallen. Family Member 2 stated the resident did not look like herself; her speech was slurred and her face looked "damaged." When asked to explain "damaged," Family Member 2 stated the resident's eyes were vertically bigger than normal, as though her eyes were opened too much.
Family Member 2 stated the resident remained awake throughout the night until approximately 0600 hours. The family member did not answer when asked what had happened. Staff brought in the resident's breakfast at approximately 0800 hours. Family Member 1 tried to awaken the resident to eat; however, the resident was very drowsy and only ate one bite. After breakfast, the resident just stayed asleep. At 1200 hours, Family Member 1 became concerned and asked the nurse to check the resident. The staff called 911 and the resident was transferred to the acute care hospital emergency department.
When asked how often the staff checked Resident 2 during the night, Family Member 2 stated three or four times before breakfast. The family member stated the staff stood by the resident's bed and looked at her; they did not do anything. When asked if they looked in the resident's eyes with a light, asked her questions, or checked her hand grips, Family Member 2 stated no.
On 7/20/17 at 1140 hours, a telephone interview was conducted with LVN 5. LVN 5 was asked to describe the events surrounding Resident 2's transfer to the hospital on XXXXXXX16. LVN 5 stated when she made rounds on Resident 2 at 0830 hours, the resident was sleeping. LVN 5 did not recall if she entered the room or if she spoke to any of the family members. LVN 5 stated she was working as the desk nurse on 11/28/16.
LVN 5 stated while LVN 1 was on lunch break, Resident 2's CNA asked LVN 5 to check on the resident. When LVN 5 went to Resident 2's room, the family members were very concerned because the resident had been very sleepy since the morning. LVN 5 stated the resident was very lethargic; she checked the resident's blood sugars and vital signs and told the family the resident needed to be sent to the hospital. The family was indecisive about waiting for the resident's physician's versus transferring the resident to the acute care hospital. LVN 5 called RN 1 to Resident 2's room. RN 1 agreed the resident should be sent to the acute care hospital and the family agreed. The paramedics were called and arrived very quickly to transport the resident to the acute care hospital emergency department.
LVN 5 was asked how the resident was assessed. LVN 5 stated the resident's vital signs, blood sugars, and oxygen saturation levels were assessed. LVN 5 stated she shook the resident's shoulder to arouse her and the resident did not respond. LVN 5 and RN 1 both did a sternal rub; the resident did not open her eyes but might have moaned and moved a little. RN 1 stated she performed a neurological exam on Resident 2. LVN 5 stated prior to being asked to check, Resident 2 by the CNA, she had not heard about any concerns about the resident's condition other than the resident was being monitored due to a fall.
On 7/20/17 at 1408 hours, a telephone interview was conducted with CNA 3. CNA 3 was asked to describe the events the night of 11/27/16, and early morning 11/28/16 for Resident 2. CNA 3 stated she made the initial rounds on Resident 2 at approximately 2300 hours on 11/27/16. The resident was awake, alert, and denied any pain or the need to use the bathroom. The call light was within the resident's reach.
CNA 3 stated she had not seen the resident again until the charge nurse called for help. When CNA 3 entered Resident 2's room, Resident 2 was lying on the floor near the bathroom with her head towards the door to the room, she was propped up on her elbow holding her head up. The charge nurse asked Resident 2 if she had hit her head and the resident stated no, just her leg hurt. After the nurse assessed the resident, four staff members lifted the resident to the wheelchair and then to the bed with a draw sheet. CNA 3 stated she did not enter the resident's room again until the last rounds because the family was there and the nurse kept going in the room. At last rounds the resident was awake, but quiet; she did not speak.
On 7/20/17 at 1410 hours, a follow-up telephone interview was conducted with LVN 1. LVN 1 was asked to explain her documentation about Resident 2 being "still asleep but responsive to verbal and tactile stimuli," written on 11/28/17 at 1058 hours. LVN 1 stated the resident was asleep, but when she called the resident's name and tapped on her shoulder, the resident did not speak or move, but the resident's eyes moved under her eyelids.
When asked, LVN 1 verified she performed the neurological exam on 11/28/16 at 0755 hours. LVN 1 stated she checked the resident's pupils for size and reaction using a penlight, she asked the resident to her squeeze her hand and checked for level of consciousness by checking if the resident was alert. LVN 1 stated she did not recall how she checked the resident for movement. LVN 1 stated the resident was asleep and she tried to awaken the resident. LVN 1 stated the resident responded more to touch than verbal commands or questions, but she did not fully wake up.
LVN 1 stated she thought Resident 2 was tired. When asked if she correlated her finding on the neurological exam with a change in the resident's neurological status, LVN 1 stated no, she thought the resident was tired and sleeping. When asked if she had informed Resident 2's physician of the resident's change in level of consciousness, LVN 1 stated no. When LVN 1 was asked if she attempted to awaken the resident at the time she went in to administer the resident's medications at 0945 hours on 11/28/16, LVN 1 stated no. LVN 1 stated she never saw the resident's eyes open during her shift.
On 7/20/17 at 1540 hours, a telephone interview was conducted with RN 2. RN 2 was asked how she assessed Resident 2 the early morning of 11/28/16. RN 2 stated she asked the resident if she was in pain (the resident pointed to her hip). RN 2 stated Resident 2 denied hitting her head. She stated Resident 2 could move her arms but could barely move her left leg due to recent surgery. RN 2 stated she performed a neurological exam: Resident 2's pupils were equal, her hand grasps were equal, and her vital signs were normal. The resident knew her name, where she was, and explained she was trying to go to the bathroom. RN 2 stated she performed a body assessment and Resident 2 did not have any new bruises or skin tears.
RN 2 stated she communicated several times with Resident 2's family who was visiting in Resident 2's room and each time the resident was awake and speaking with the family. RN 2 did not observe anything unusual in how the resident acted or looked.
When asked if she had performed Resident 2's neurological exams, RN 2 stated she had only performed the first one, the charge nurse (RN 2) had performed the rest of them during the shift.
On 7/21/17 at 0942 hours, a telephone interview was conducted with LVN 6 regarding the events surrounding Resident 2's fall. LVN 6 stated she heard Resident 2 calling for help not too long after the start of the shift on 11/28/16. LVN 6 stated she found Resident 2 lying on the floor on her side. LVN 6 stated she called for the RN and CNA to help. LVN 6 stated Resident 2 told her she was trying to go to the bathroom. LVN 6 stated Resident 2 denied hitting her head. LVN 6 stated after assessing the resident and transferring her back to bed, LVN 6 called the resident's physician and family. LVN 6 stated three or four family members came to the facility.
LVN 6 stated she spoke with Resident 2's family members and recommended to transfer the resident to the hospital for evaluation; however, the family wanted to wait for the physician's recommendations.
LVN 6 stated RN 2 was the main nurse communicating with Resident 2's family while she was making phone calls and doing paperwork. LVN 6 stated RN 2 performed all of the neurological assessments. LVN 6 stated she asked the CNA to take Resident 2's vital signs. LVN 6 verified she documented the results of RN 2's assessments on the Neurological Flow Sheet. When asked LVN 6 denied performing the neurological assessments for Resident 2. LVN 6 stated RN 2 performed the neurological exams and then told LVN 6 the information to document on the flow sheet.
According to the Mayo Clinic, symptoms and causes of an intracranial hematoma can be life threatening. With time as pressure on the brain increases, some or all of the following signs and symptoms may be produced: increasing headache, drowsiness and progressive loss of consciousness, dizziness, confusion, unequal pupil size and slurred speech. As more blood fills the space between the brain and skull, other signs and symptoms may become apparent, such as: lethargy, seizures, and unconsciousness.
Review of Resident 2's acute care hospital emergency department's medical record showed Resident 2 was admitted to the acute care hospital on XXXXXXX16, with altered mental status. The emergency department physician's neurological exam showed "No speech. Patient is obtunded (a depressed level of consciousness and cannot be fully aroused). She has some movement to bilateral lower extremities and left arm but none noted to the right upper extremity. The resident's eyes showed the right pupil was "possibly 1 mm (millimeter) larger than the left."
Results of a CT scan (from the acute care hospital) of the brain completed on 11/28/16 at 1425 hours, showed Resident 2 had a 3.5 cm (centimeter) right-sided subdural hemorrhage with a 2.6 cm right to left midline shift.
Review of Resident 2's Certificate of Death showed the resident expired on XXXXXXX 16 at 0430 hours. The primary Cause of Death was listed as massive subdural hematoma, non-traumatic.
b. Review of Resident 2's physician's orders dated 11/10/16, showed an order for an abductor pillow at all times while in bed.
Review of Resident 2's MAR (medication administration record) dated November 2016, showed an entry for an abductor pillow at all times while in bed every shift. The MAR showed the nurses' initials for every shift, starting with the evening shift on 11/1/16, through the day shift on 11/28/16.
On 7/20/17 at 0840 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated she visited Resident 2 on 11/27/17. Before Family Member 1 left at 2100 hours, she walked the resident to the bathroom using the resident's walker. Family Member 1 stated the resident did not have the abductor pillow between her legs when she got her up. Family Member 1 stated when she arrived back at the facility later at 0330 hours, the abductor pillow was in the chair where it had been when she left the night before. Family Member 1 stated if the abductor pillow had been between the resident's legs the resident could not have gotten out of bed by herself because the abductor pillow was attached to the resident's legs with Velcro straps.
On 7/20/17 at 1408 hours, a telephone interview was conducted with CNA 3 regarding the events the night Resident 2 fell. CNA 3 stated she made rounds on 11/27/16 at 2300 hours. CNA 3 stated the resident was supposed to have the abductor pillow placed between her legs due to the recent hip surgery. The CNA from the previous shift reported the resident's abductor pillow was not in place. CNA 3 stated she asked the resident, the resident told the CNA she did not want it on yet, so CNA 3 did not put it in place. The CNA stated she did not see the resident again until she was called to the resident's room when the resident fell.
On 7/21/17 at 0942 hours, a telephone interview was conducted with LVN 6. When asked about Resident 2's abductor pillow the night the resident fell, LVN 6 stated she had not noticed it was not in place and had not seen Resident 2 the night Resident 2 fell.
In conclusion, the facility failed to inform Resident 2's physician of the continued deterioration of Resident 2's neurological status as evidenced by a decline in her cognition, mobility, and severe sleepiness after an unwitnessed fall in the facility. The facility also failed to use the abductor pillow as ordered by the physician.
These violations jointly, separately or in any combination, presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result. |
| 070000789 |
TUPAZ HOME #3 |
070012447 |
B |
8-Aug-16 |
Q9LE11 |
4776 |
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 ensure Client 1's right to prompt medical care and treatment. The facility failed to exercise operating directions when direct care staff A (DCS A) did not start cardio pulmonary resuscitation (CPR) on Client 1 as the facility's policy and procedure indicated and when no CPR board was available to perform CPR in bed. This failure resulted in Client 1's death. During a record review on 7/21/16, it indicated Client 1 had diagnoses including profound mental retardation, hydrocephalus with VP shunt (ventriculo-peritoneal shunt- a surgical procedure used to treat hydrocephalus or excess fluid in the brain), borderline diabetes mellitus, neurogenic bladder and status post nephrostomy. He required total assistance with his activities of daily living. His record contained a "Physician Order for Life-Sustaining Treatment " dated 7/6/15 that indicated to attempt resuscitation/CPR and to provide full treatment as a medical intervention. The facility incident report dated 7/10/16 indicated on 7/9/16 at 9:58 p.m. DCS A caring for the clients called licensed nurse B (LN B) and reported the client's skin color was pale and he was unresponsive. LN B advised DCS A to call 911. 911 was called and the paramedics instructed DCS A to transfer the client on the floor and start CPR. DCS A attempted to transfer the client but was not able to because the client was "big and heavy". At approximately 10:06 p.m., the paramedics arrived and did the resuscitation. At 10:34 p.m., the client was pronounced dead and the paramedics left the facility. During an interview on 7/21/16 at 12:40 p.m., DCS A stated she made her first round to see all clients at approximately 7:30 p.m. and Client 1 was asleep in bed. DCS A stated she made the second round at approximately 9:40 p.m. and she saw Client 1 had very pale skin color and he was not responding. She called Client 1's name and shook him by his legs but without response. She thought Client 1 was not breathing and she was not able to take a pulse. She took the client's pulse saturation (a means to measure blood oxygen level) and the result was a low reading at 50% mmHg (millimeters of mercury). She then called LN B who advised her to call 911. She stated she was instructed by the dispatcher to transfer the client to the floor but she told them she was not able to do so because the client was too heavy for her to transfer to the floor. She only observed the client until the paramedics arrived. During another interview on 7/21/16 at 3:00 p.m., LN B stated DCS A called her at about 9:58 p.m. and told her that Client 1 was pale in color and was unresponsive. She stated she advised DCS A to call 911. She stated she arrived at the facility and saw the paramedics with the client. She said the paramedics told her the client must have been dead for some time. She stated she was at the facility earlier on the day of the incident, made her rounds, saw all the clients in bed and left at about 7:55 p.m. During an observation on 7/21/16 at 4:14 p.m., along with LN C and the qualified intellectual disability professional (QIDP), they acknowledged no hard board was available for the staff to perform CPR in bed. During a concurrent interview at 4:15 p.m., LN C and the QIDP stated the facility had an "Adult Manual Resuscitator" but the facility did not have a resuscitator board. Record review of the facility's policy and procedure for "Immediate Emergency" included for staff to call 911 and to begin CPR if indicated, and continue until the client responded. However, DCS A failed to perform CPR when Client 1 was observed to be pale in color and was unresponsive. Further, the facility did not have a resuscitator board to assist the staff in performing CPR. The facility failed to ensure the client's right to prompt medical care and treatment. The staff did not perform CPR when the client was observed to be very pale and not being responsive. The violation had a direct or immediate relationship to the health, safety or security of the clients. |
| 070000778 |
THE TERRACES OF LOS GATOS |
070012469 |
B |
12-Aug-16 |
N6Y911 |
3647 |
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 report an alleged abuse incident between two residents in a timely manner. This had the potential for continued abuse, mental anguish, and diminished dignity of the affected resident. Resident 2 was recently admitted to the facility for rehabilitation services after an acute hospital stay for pneumonia (an acute lung infection). Her clinical record MDS (minimum data set, an evaluation tool for mental and physical assessments of patients) dated 6/21/16, indicated she was alert, oriented, and able to make her own medical decisions. A review of the facility's undated investigative report indicated that on 6/24/16, an occupational therapy assistant (OTA) was working with Resident 2 as part of the rehabilitation process. Resident 2 told the OTA that she was feeling upset from being spoken to inappropriately by her roommate, Resident 1. She stated that Resident 1 had called her a "cow" and the next time she coughed loudly Resident 1 said, "I hope you choke to death and die." The report further indicated the alleged incident was reported to the interdisciplinary team (the facility's various department heads) on 6/27/16 by the director of rehabilitation. During an interview with the OTA on 7/20/16 at 1:28 p.m., she stated on 6/24/16 before noon she had a therapy session with Resident 2, and she related what Resident 1 had said to her. The OTA stated she informed the director of rehabilitation (DOR) of the incident after the therapy session with Resident 2. Additionally, the OTA stated she had told the unit charge nurse (UCN) about what Resident 2 told her had happened to her. During an interview with the DOR on 7/20/16 at 2:10 p.m., she acknowledged the OTA had told her of the incident on 6/24/16 before noon. The OTA told her she had also informed the unit charge nurse (UCN), and DOR assumed it was being reported to management through the UCN. The DOR stated on 6/27/16, she brought up the incident during the morning stand up meeting, (daily meeting made up of administrator, director of nursing and all department heads) and recognized the team was not aware of the incident. During an interview on 7/21/16, at 10:55 a.m., the UCN stated she had not been informed of any alleged verbal abuse between Resident 1 and Resident 2 by the OTA. She added she did not know who was the OTA. During an interview on 7/22/16, at 9:35 a.m., the facility administrator stated the alleged abuse incident was not reported in a timely manner in accordance with the facility's policy and procedure. Review of the facility's 4/2010 policy and procedure, "Reporting Abuse to Facility Management," indicated, "verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families..." It further indicated, "Any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report, or cause a report to be made of, the mistreatment or offense." Therefore, the facility failed to implement their abuse policy and procedure when they failed to report the alleged abuse incident in a timely manner. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to residents. |
| 070001404 |
TUPAZ HOME #11 |
070012640 |
B |
17-Oct-16 |
9OZQ11 |
8106 |
W 331 - 483.460(c) NURSING SERVICES The facility must provide clients with nursing services in accordance with their needs. The facility failed to ensure the physician's order for wound care treatment was implemented, ensure the registered nurse (RN) assessed the client's bilateral lower extremities' wounds regarding their foul odors, and ensure promptly scheduling an appointment to a wound clinic for Client 1. These failures may potentially affect the client's health and safety in the facility. Review of Client 1's clinical record on 10/3/16 indicated Client 1 was admitted to the facility with diagnoses including mild developmental disabilities, diabetes insipidus (a condition characterized by excessive thirst and excretion of large amounts of severely diluted urine, with reduction of fluid intake), and chronic wounds on both legs with ulcerations (sores on the skin) and edema (swelling). The nurse's notes dated 9/21/16 indicated Client 1 was taken to an acute care hospital due to maggots (fly larva) found on his left foot wound during a dressing change. Client 1 was admitted to the hospital on the same day. He was discharged from the hospital on 9/25/16 with a diagnosis of cellulitis (a bacterial infection involving the inner layers of the skin). A physician order dated 9/3/16 indicated the following: "Cleanse wound with NS [normal saline, a solution of sodium chloride in water], pat dry, apply adaptic [clear occlusive non-adhering wound dressing made of knitted cellulose acetate fabric and impregnated with a specially formulated petrolatum emulsion) on the wound site, cover with ABD pad [absorbent pad], wrap with kerlex [a gauze bandage roll which provides fast-wicking action, superior aeration, and excellent absorbency] and an ace bandage [an elastic bandage designed to provide support and compression], then coban [a self-adherent wrap made of a porous, non-woven polyester material], daily in p.m. [one leg then alternate with the other leg]. Soak wound in daikins solution" [antiseptic solution containing sodium hydrochloride and developed to treat infected wounds]. On 9/8/16, the primary physician ordered to "Soak bilateral legs with daikins solution every day and wash with normal saline and apply prescribed treatment." Licensed vocational nurse B (LVN B) noted the order. Review of the treatment record on 10/3/16 indicated the licensed nurses did wound dressing changes every other day on alternating legs from 9/3/16 through 9/21/16 until Client 1 was transferred to the hospital. There was no evidence the physician's order dated 9/8/16 for the wound treatment was implemented. The "non-pressure sore skin problem weekly progress report" dated 9/3/16, 9/10/16, and 9/17/16 indicated they were signed by LVN B who performed the wound dressing change and assessment. There was no evidence a registered nurse (RN) assessed the wounds. A review of the 2015 Board of Registered Nursing, Business and Professions Code indicated, "direct and indirect resident care services, included, but were not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention or rehabilitative regimen ordered within the scope of licensure of a physician, as defined by Section 1316.5 of the Health and Safety Code. Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and (A) determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and (B) implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures." Review of the nurse's notes dated 9/18/16 indicated a foul odor was noted during the dressing change as documented by LVN B but no evidence the physician was informed. During an observation in the facility on 10/3/16 at 7:15 a.m., Client 1 was wearing short pants. Client 1's swollen legs (the left was larger than the right) were tightly wrapped with thick dressing and covered with coban. The entire legs, ankles, tops and bottoms of the feet except the toes were covered with dressing (looked like a space boot). His toes' exposed skin was darkish-brown, dry, and scaly. Client 1 used a cane to ambulate around the facility and wore slippers. He was alert and oriented times three (oriented to time, place, and person). During a concurrent interview Client 1 stated he had wounds on his legs for almost 18 years, and had started on his left leg. He stated he had a medical condition in which his veins could not pump enough blood back to the heart causing swelling of both legs, and he needed the bandages on his legs. He stated the facility nurses changed his wound dressing every other day on an alternate schedule with the other leg. He stated it was not enough. He stated he was anxious for his wound clinic appointment on 10/3/16 because he would meet a new physician. Client 1 stated his wound dressing was last changed when he was released from the hospital "a week ago", and the wound physician would see him for the first time since he was admitted to the facility. Client 1 stated this was the first time maggots (fly larva) were found on his wound. Client 1 also stated sometimes he saw a fly in the kitchen. He stated he sometimes opened the door to the backyard because the weather was hot. During an interview on 10/3/16 at 10:55 a.m., with LVN A. she stated on 9/21/16 Client 1 was scheduled for the left leg dressing change. She stated Client 1's wound did not look good. Upon removing the dressing, LVN A was stunned to observe maggots on the left dorsal foot wound. She instructed Client 1 to soak his left foot in the basin with solution to wash away the maggots, and replaced the basin with clean, warm water to rinse the wound. She applied a new dressing and reported it to the house physician who ordered the client be transferred to the hospital. During an interview with the registered nurse (RN) on 10/3/16 at 9:50 a.m., she stated she did not change Client 1's dressing on 9/21/16. She acknowledged the dressing change was done every day but on alternate legs. She also could not provide documentation that Client 1's initial wound assessment was done by an RN. She stated Client 1 preferred to walk barefoot in the facility and would open the door going to the backyard. During an interview on 10/4/16 at 11:45 a.m. with the primary physician, she acknowledged she changed the wound care order on 9/8/16 and wanted both legs soaked and dressing changed daily. She stated she was notified by staff the client went home against medical advice (AMA) the evening of 10/3/16. During an observation and interview with LVN B, who was the facility's lead licensed vocational staff on 10/4/16 at 3:50 p.m., LVN B confirmed Client 1 went home with his family member against medical advice on 10/3/16 at approximately 6:30 p.m. The physician was notified. She acknowledged she overlooked the physician's order on 9/8/16 and did the dressing change every other day alternating the legs instead of daily for both legs. She also confirmed the facility was using a basin for soaking the foot and not soaking the entire leg as ordered. LVN B admitted she did the wound progress notes and assessed the wound and these were not done by the RN. LVN B confirmed she did not implement and document the change in wound treatment in the progress notes. She stated she was not able to schedule the wound clinic appointment at an early time. The facility failed to follow the physician's order for daily dressing change and daily soaking of both legs with daikins solution. The RN did not assess the wound when a foul smell developed, and the wound clinic appointment was not scheduled promptly. The client developed an infection and maggots were found in his left foot wound. Client 1 was admitted to the hospital. This violation had a direct relationship to the health, safety, or security of clients. |
| 070000998 |
TUPAZ HOME #7 |
070012692 |
B |
31-Oct-16 |
88YU11 |
4067 |
W153 -- 483.420(d)(2) STAFF TREATMENT OF CLIENTS The facility must ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with State law through established procedures. The facility failed to ensure allegations of verbal and physical abuse was reported in writing immediately to other officials in accordance with state law. Client 1 alleged that direct support professional A (DSP A) committed verbal and physical abuse during a diaper change and personal care. The allegation was not reported to the California Department of Public Health as required. This failure had the potential for continued verbal and physical abuse of the clients by a suspected abuser. Client 1's clinical record was reviewed and indicated she had diagnoses including cerebral palsy (a group of permanent movement disorders that appear in early childhood). The Comprehensive Functional Assessment (CFA, assessment tool) dated 8/19/15 indicated Client 1 was verbal and could express her needs. Client 1 relied on her wheelchair for translocation, and could self-propel slowly around the facility. Client 1 had her own cellphone and had the ability to use the phone independently. During a review of Client 1's clinical record on 9/19/16, nurse's notes dated 8/16/16 indicated Client 1 alleged DSP A hit her on her right cheek and grabbed her left wrist. The registered nurse (RN) assessed Client 1 and did not observe any reddened area or sign of trauma. The family member and RP (responsible person, and individual or group of individuals legally responsible for a decision or action and therefore liable for the outcome for an individual) took Client 1 home that night because "they do not feel the client was safe in the facility." The physician was informed. There was no documented evidence the RP signed an "against medical advice" (AMA) form. On 9/19/16 at 8:55 p.m. during a concurrent interview with the qualified intellectual disabilities professional (QIDP) she confirmed Client 1 alleged DSP A of verbal and physical abuse during a diaper change at around 7:00 p.m. The QIDP stated a police officer arrived that night and concluded there was no crime committed. The QIDP acknowledged the incident was not reported to the California Department of Public Health. During a telephone interview on 9/16/16 at 2:40 p.m. with the RP, he stated a family member (FM) called him stating Client 1 and the FM were talking over the telephone when FM overheard DSP A yelling at Client 1 instructing Client 1 to hang up the phone. FM overheard Client 1 saying "cannot touch the phone." RP stated FM went immediately to the facility. During an interview with direct support professional (DSP A) on 9/19/16 at 3:35 p.m., she stated she reminded Client 1 several times that it was time for cleanup but Client 1 wanted to stay in the living room longer. Client 1 yelled at DSP A and refused to change her diaper. After a while, DSP A was able to change Client 1's diaper. DSP A stated at 7:45 p.m., FM arrived and later the RP arrived to the facility and accused DSP A of hitting and yelling at Client 1. Client 1 maintained what FM said and confirmed DSP A hit her on her cheek and grabbed her left wrist. DSP A also stated she was not aware Client 1's cellphone was open. DSP A stated she never hit Client 1. During an interview with the registered nurse (RN) on 9/19/16 at 12:40 p.m., RN confirmed he assessed Client 1 and observed no reddened area or trauma. The RP and FM took Client 1 home that night. A review of the facility's policy and procedure "Tupaz Homes Inc. Procedures" indicated all allegations of mistreatment, neglect or abuse, as well as significant injuries, of unknown source, will be reported immediately to the administrator. All staff will act as the mandated reporter per Section 15830 of the California Welfare and Institutions Code. The above violation had a direct or immediate relationship to the health, safety, or security of the client. |
| 070000568 |
TUPAZ HOME #10 |
070012880 |
B |
30-Jan-17 |
NCIY11 |
5704 |
W347 - 483.460(d)(5) NURSING STAFF Non-licensed nursing personnel who work with clients under a medical care plan must do so under the supervision of licensed persons. The facility failed to ensure the direct support professional (DSP) was supervised by a licensed nurse during a gastrostomy tube (GT, a surgical opening into the stomach to administer nutrition and medication) unclogging procedure, failed to ensure a physician was informed and order was obtained for unclogging, failed to ensure the facility had a policy and procedure for unclogging the GT, and failed to ensure licensed nursing staff performed the procedure. These failures may potentially affect the clients' health and safety in the facility. Client 3 had diagnoses including severe developmental disabilities and had a GT for nutrition and medication administration. The comprehensive functional assessment (CFA, an assessment tool) dated 9/30/16 indicated Client 3 was nonverbal. Client 3 was alert and receptive and responded by nodding or moving his eyes and eyebrows for "yes" and moving his head side-to-side for "no". Client 3 used a manual wheelchair customized for his needs and used it for translocation. During medication pass observation on 1/9/17 at 6:45 a.m. with DSP A, DSP A prepared Client 3's morning medications per GT without washing his hands before preparing the medications. DSP A crushed 10 medication tablets to administer per GT. DSP A crushed a total of 5 Docusate Sodium tablets (a stool softener), placed them in two separate medication cups, and dissolved each in 10 milliliters (ml, unit of measurement) of water each. DSP A crushed the remaining five medication tablets and dissolved each in 10 ml of water. DSP A exposed the GT, checked the GT placement, and residual. DSP A poured 30 ml of water into the GT to flush and poured one by one the dissolved medications without flushing before and after each medication administration. The GT tube clogged. DSP A took an opened paper covered "DeClogger" (a plastic, flexible and bristly stick device that punctures through obstructed enteral feeding tubes) from Client 3's bedside drawer, inserted it into the clogged GT, twisted it and pulled it out. The flow started and DSP A was able to administer all the medications. DSP A poured 30 ml of water to flush the GT. DSP A washed the DeClogger device and placed it back inside the paper cover. During a concurrent interview with DSP A, he stated he did not have training using the DeClogger, and he was not aware of a policy and procedure for using the DeClogger. He confirmed he only flushed the GT tube before administering all the medications, and after all the medication was administered and not after each medication administration. He acknowledged he did not wash his hands prior to preparing the medications. During an interview with the licensed vocational nurse (LVN) on 1/9/17 at 5:30 p.m. and 1/10/17 at 2:35 p.m. the LVN stated she had not used the DeClogger, and she did not train staff on using the DeClogger. The LVN confirmed the facility had no policy and procedure for the DeClogger. The LVN admitted she brought the Declogger to the facility for emergency use only, and she should not have done so. She stated she notified the physician and the physician ordered stat (a diagnostic or therapeutic procedure that is to be performed immediately) an abdominal X-ray (imaging that creates picture of the inside of the body) on the same day. During an interview with the registered nurse (RN) on 1/10/17 at 9:50 a.m., the RN stated she did not receive a call from the facility regarding a problem with Client 3's GT. The RN stated she did not know about the DeClogger and had not used one. The RN stated the physician had to be notified about the problem with the GT and needed a physician order to unclog using a DeClogger. During an interview with the physician on 1/11/17 at 2:30 p.m. she stated she usually ordered to try something else first such as flush the GT with a cola drink, and if unsuccessful she ordered to take the client to the hospital emergency room for evaluation and unclogging. The physician stated if the RN is trained to do the DeClogger, the RN may perform the DeClogger at the facility per the facility's policy and procedure. Review on 1/10/17 of the manufacturer's label on the declogger paper cover "DeClogger Enteral Feeding Tube DeCloggers by Bionix" indicated a procedure for the DeClogger use: 1. Select the proper size DeClogger that conforms to the length and diameter of the patient's tube. 2. Verify the tube length and confirm that no alterations have been made to the tube. 3. Gently insert the threaded end of the DeClogger into the tube using a twisting motion. 4. After penetrating the clog, gently slide the DeClogger up and down to dislodge the obstruction. 5. Flush the feeding tube with the appropriate solution. The DeClogger can only be used by a licensed Medical Professional. The DeClogger is intended for single use only and does not require sterilization. "Caution: Federal law restricts this device to sale by or on the order of a physician." The facility failed to ensure a licensed nurse performed unclogging the GT with the DeClogger. The facility failed to ensure a direct support professional was supervised by licensed staff for the procedure. The facility failed to ensure a policy and procedure for the DeClogger was developed. The facility failed to ensure a physician was notified and obtained an order for the DeClogger which resulted in Client 3 having to have a stat abdominal X-ray conducted after the DeClogger procedure was done. This violation had a direct relationship to the health, safety, or security of clients. |
| 070000998 |
TUPAZ HOME #7 |
070013248 |
B |
2-Jun-17 |
OL3D11 |
8665 |
W318 -- 483.460 HEALTH CARE SERVICES
The facility must ensure that specific health care services requirements are met.
The facility failed to ensure the admitting registered nurse consultant (RNC) informed the receiving direct support professional (DSP) about Client 1's condition and physician orders, including the prescribed diet; failed to ensure that Client 1's admitting orders were complete when Client 1's renal diet order from the acute care hospital was not copied to the facility's admission orders, as well as Client 1's central line shunt (dialysis catheter) and monitoring of blood sugar level while Client 1 was on insulin (a medication to treat high blood sugar) and insulin subcutaneous injection (sub-Q, a shot that delivers medicine into the layer of fat between the skin and the muscle); failed to ensure Client 1's insulin order was written in the medication administration record (MAR); failed to ensure Client 1's routine insulin medications, including the sub-Q injection, were started on admission; failed to ensure that Client 1's assessment, including a full examination of body systems, was completed; and failed to ensure Client 1's care plans were initiated. These failures placed Client 1's health and safety at significant risk and the client was readmitted to an acute care hospital with diagnoses of hypoglycemia (low blood sugar), altered mental status, and the central line was pulled out.
Client 1 was admitted to the facility from an acute care hospital on XXXXXXX 17 with diagnoses including diabetes (a disease in which the body has elevated blood sugar), end stage kidney disease and on dialysis treatment (a treatment that performs some of the functions of healthy kidneys). The level of placement assessment from the regional center (a center that provides services to individuals with developmental disabilities), dated 2/2/17, indicated Client 1 had moderate intellectual disabilities (intellectual functioning level as measured by standard tests for intelligence quotient) that are well below average and having significant limitations in daily living skills (adaptive functioning).
During an interview with direct support professional A (DSP A) on 3/22/17 at 6:30 a.m., DSP A stated Client 1 arrived at the facility on XXXXXXX 17 at 2:00 p.m. from an acute hospital in the facility van. DSP A stated the van's driver told her the registered nurse consultant (RNC) would be coming soon with the medical record and information about the client. DSP A stated Client 1 was hungry at dinner but DSP A was not aware what Client 1 could eat. DSP A stated she found a can of Ensure (nutritional supplement) inside Client 1's backpack and gave that to Client 1 for dinner. DSP A stated she did not call the RNC because she was told the RNC was coming. DSP A stated the RNC did not arrive at the facility until approximately 7:00 p.m. when DSP A was about to end her shift.
During a telephone interview with the RNC on 3/22/17 at 10:05 a.m. she stated she drove to the hospital and did not go to the facility with Client 1 in the facility's van. The RNC stated she went to the facility but could not exactly state the time of her arrival, and was not aware Client 1 had a can of Ensure for dinner and a can of Mighty Shake for breakfast the following day. The RNC was not aware Client 1 did not receive his medications on 2/18/17. The RNC stated she administered the insulin to Client 1 but forgot to document it. The RNC acknowledged she did not perform a complete body system assessment during Client 1's admission, and no care plan was developed for the direct support professionals to follow.
During a review, on 3/22/17 at 10:00 a.m., of Client 1's discharge instructions from the acute care hospital, the facility's written admission orders were not completely transcribed: there was no diet order, and Client 1's central line order was not in the facility's admission orders. Also, there was no blood sugar monitoring although the client was prescribed insulin, Regular Human Novolin 70/30, sub-Q injection, in the morning and afternoon. Client 1 was also prescribed glipizide (used to treat high blood sugar) and Sitagliptin (used to reduce blood sugar) medication and other routine medications which also were not listed in the client's admission orders.
A review of the medication administration record (MAR) at the same time indicated the physician's order for "Insulin Regular Human (trade name: Novolin R) give Novolin 70/30 sub-Q, 32 units in AM, 28 units PM," was prescribed but not transcribed into the MAR. There was also no blood sugar monitoring or central line care noted in the MAR. The routine medications due in the afternoon on admission day were not started.
On 3/23/17 at 1:45 p.m., during an interview with the RNC at the day program, she acknowledged she did not completely clarify with the facility's physician (FP) the discharge instructions from the acute care hospital. She acknowledged she missed copying Client 1's diet to the facility's admission orders, that the insulin sub-Q medication was not transcribed into the MAR, and that there was no blood sugar monitoring order, although Client 1 was on insulin (a hormone that works by lowering the blood sugar level) therapy every morning and afternoon. In addition, the central line shunt care was not documented in the facility's admission orders. The RNC also stated she administered the insulin to the client on the day of admission but did not document it. She confirmed there was no care plan developed for the DSP to follow.
During an interview with the FP on 2/23/17 at 2:35 p.m., the FP acknowledged that the diet, central line and blood sugar monitoring were not ordered for Client 1 in the facility's admission orders. The FP stated blood sugar monitoring was not always ordered for clients on insulin therapy. The FP stated the staff overlooked the diet and central line orders.
During an interview with DSP A on 3/23/17 at 3:35 p.m., she stated the facility had no insulin medication in the facility because there were no clients with physician orders for insulin. DSP A confirmed that, on 2/18/17, Client 1's medication orders from the acute care hospital, apixaban (medication to prevent blood clots), glipizide (medication to control blood sugar) and Protonix (medication to decrease the amount of acid in the stomach) for 5:00 p.m. and 7:00 p.m. were not given on admission because they were not available. DSP A stated she gave all the medications the following day. DSP A stated when she checked on Client 1in his room on 2/19/17 at 9:00 a.m., Client 1 was confused. DSP A stated the central line on the client's right upper chest was partially out and Client 1 was bleeding at the site.
On 3/22/17, the facility's policy and procedures, "Care Plans, Director of Nursing, Administration/QMRP and Administration of Medication," were reviewed and indicated the following: an individualized care plan is developed for each client at the time of admission. Clients' needs and problems that are identified will be entered on the care plan. The RN participates in admission and discharge planning for the clients. The RN communicates with the physician as necessary according to the clients' needs, facility policies, and government regulations. The charge nurse is responsible for the execution of doctor's orders and reports and records. All medications are administered according to the physician's order.
On 3/27/17, a review of the hospital's discharge information indicated that, on XXXXXXX17, Client 1 was readmitted to an acute care hospital. The acute care hospital's admitting diagnoses were "hypoglycemia (low blood sugar), altered mental status, and dialysis catheter was pulled out."
On 5/26/17 at 9:45 a.m. during a telephone interview with DSP B, who worked on 2/18/17 from 8:00 p.m. until 7:00 a.m. (2/19/17), she confirmed Client 1 was already asleep when she started her shift. DSP B stated she did not give any medications to the client or feed Client 1. DSP B stated the day shift served the clients' breakfast.
The facility failed to provide appropriate nursing assessment, completely transcribe the physician orders from an acute hospital to the facility's admission orders, and timely implementation of the prescribed therapy, to prevent a significant accident of Client 1 pulling out the central line, causing him to bleed from the site and placing Client 1's health and safety at significant risk. Client 1 was readmitted to an acute care hospital on the same day.
These violations had a direct relationship to the health, safety, or security of the clients. |
| 070000476 |
TUPAZ HOME |
070013397 |
B |
2-Aug-17 |
ISRL11 |
5014 |
W331 - 483.60(c) NURSING SERVICES
The facility must provide clients with nursing services in accordance with their needs.
The facility failed to ensure clients were provided with nursing services according to their needs when Client 1 had an onset of shortness of breath (SOB) while in a wheelchair, and no nursing intervention to provide oxygen supplement (O2, given as treatment for clients with difficulty breathing) was initiated. This failure affected Client 1's health condition, the facility had to call emergency assistance (911) and then Client 1 was transferred to an acute hospital where Client 1 expired in the Emergency Department (ED, the department of a hospital responsible for the provision of medical and surgical care to patients arriving at the hospital in need of immediate care).
Review of Client 1's clinical record on 7/19/17, indicated Client 1 had diagnoses including mild mental developmental disabilities, spastic quadriplegia (most severe form of spastic Cerebral Palsy, abnormal body movement affecting all four limbs), and cancer of the urinary bladder. The comprehensive functional assessment (CFA, assessment tool) dated 4/12/17 indicated Client 1 was verbal and needed total assistance in her activities of daily living (ADL).
The nurse's notes dated 7/13/17 at 9:20 a.m., indicated the registered nurse (RN C) noted Client 1 had "deep rapid respiration." At 9:25 a.m. emergency assistance (911) was called. At 9:30 a.m., the paramedic (a person who is trained to give emergency medical treatment) assessed the client and started cardiopulmonary resuscitation (CPR, an emergency technique used on someone whose heart or breathing has stopped). Client 1 was transferred to an acute hospital. At 9:50 a.m., Client 1 was pronounced dead in the acute hospital. There was no evidence of documentation that O2 therapy was initiated at the facility to help the client with breathing or that the staff notified the physician to manage Client 1's SOB.
During a telephone interview with direct support professional A (DSP A) on 7/19/17 and 7/24/17 at 8:10 a.m. and 3:30 p.m., DSP A stated that in the morning of 7/19/17, Client 1 had a large stool. DSP A stated Client 1 refused to shower but was given a shower for her doctor's appointment that day. DSP A also stated she noticed Client 1's abdomen was bigger at that time. After the shower, at around 7:30 a.m., DSP A stated they placed Client 1 in a wheelchair. DSP A stated Client 1 was deep breathing but thought it was normal for the client. DSP A also stated that, when talking, Client 1 could not finish a whole sentence. DSP A stated she called RN C because Client 1 looked weak and had shortness of breath.
During a concurrent interview with DSP B, she stated that at around 7:00 a.m., she helped DSP A place Client 1 on a gurney to shower her and noticed Client 1 was not talking and was weak. DSP B stated while Client 1 was in the wheelchair waiting for pick up for her appointment, the client looked different and she made DSP A call RN C to assess her.
During an interview with RN C on 7/19/17 at 9:10 a.m., RN C stated she observed Client 1 was sitting in the wheelchair responsive but had shortness of breath. RN C stated Client 1 was a full code (refers to a client in cardiopulmonary arrest, requiring a team of providers (sometimes called a "code team") to rush to the specific location and begin immediate resuscitative efforts) and called 911 due to Client 1's shortness of breath. RN C stated while the paramedic was assessing Client 1, Client 1's breathing slowed down and the paramedic started to resuscitate her. RN C acknowledged she should have initiated O2 therapy for Client 1's SOB and did not. Client 1 was transferred to an acute hospital that day. RN C also stated at 9:50 a.m. on XXXXXXX 17, the hospital informed her Client 1 was pronounced dead in the ED.
During an interview with RN D on 7/24/17 at 12:40 p.m., he stated RN C should have notified the primary physician to get an order for respiratory treatment or O2 supplement as soon as Client 1 manifested shortness of breath or developed cyanosis (a bluish tinge to the skin that is caused by a lack of oxygen in the blood).
During an interview with the primary physician (PP) on 7/24/17 at 1:05 p.m., she stated she was not informed by the facility that Client 1 had abdominal distension and shortness of breath. The PP stated the facility called her on 7/13/17 to inform her that Client 1 was transferred to an acute hospital.
Review of the facility's policy and procedure, "Oxygens" indicated oxygen is given to relieve dyspnea (shortness of breath), asphyxia (a condition of severely deficient supply of oxygen to the body that arises from abnormal breathing) and anoxemia (absence of oxygen in the arterial blood). Oxygen can be administered by licensed staff, and/or a medication certified direct care staff.
This violation had a direct relationship to the health, safety, or security of the clients. |
| 080000835 |
THE DOROTHY AND JOSEPH GOLDBERG HEALTHCARE CENTER |
080009370 |
B |
21-Jun-12 |
GMFE11 |
14119 |
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. (b) A failure to comply with the requirements of this section shall be a class "B" violation.Title 22 72521 (b) Administrative Policies and Procedures (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 follow their policies and procedures for reporting, investigating, and protecting Resident A and Resident B after two allegations of abuse were made. Certified Nursing Assistant (CNA) 1 sprayed and poured air freshener on Resident A's genitals. The facility failed to report the abuse allegation to the Department for more than 60 days, failed to conduct a thorough investigation, and failed to protect Resident A, by allowing the alleged abuser to continue caring for Resident A. In addition, CNA 2 pulled down Resident B's lip to force feed the resident, causing pain, a bruise, and an abrasion to the resident's lower lip. The facility failed to report the abuse allegation to the Department, failed to conduct a thorough investigation and the facility failed to protect Resident B and other residents, by allowing the alleged abuser to continue providing care.1. Resident A, a 93 year-old female, was admitted to the facility on 6/28/07 with diagnoses that included dementia, according to the Record of Admission. According to the Minimum Data Set (MDS) assessment dated 1/13/12, the facility assessed Resident A with moderately impaired cognitive skills and short and long-term memory problems.Resident A was totally dependent on staff for bathing, transfers, dressing, eating, toilet use and personal hygiene. Resident A was unable to walk and used a wheelchair for mobility.Resident A was observed in the dining room sitting in a wheelchair on 5/17/12 at 11:30 A.M. Resident A did not speak or acknowledge conversation.The Department received a letter from the Interim Director of Nursing (IDON) and the Director of Staff Development (DSD) on 5/14/12. According to the letter, the following sequence of events occurred:a. The allegation of abuse occurred two months prior, on 3/15/12 b. The Certified Nurse Assistant (CNA 1) was interviewed by the IDON about the allegation of abuse and he denied the allegation. c. The Ombudsman visited the facility on 4/23/12 and spoke with the IDON regarding the allegation of abuse. d. The IDON wrote that her perception from the Ombudsman was the abuse allegation, "Wouldn't be an issue." e. The facility, "Followed their policy on Elder Abuse Prevention. The employee was separated from working with the resident..." The IDON and DSD were interviewed at the facility on 5/17/12 at 9:10 A.M. The IDON stated that on 3/15/12, around the lunch hour, Student Certified Nursing Assistant (SCNA) 1 reported that CNA 1 sprayed air freshener on the genitals of Resident A, when CNA 1 changed Resident A's incontinent briefs. The IDON stated that the SCNA 1 retrieved the air freshener from the resident's room and brought it to the IDON. The IDON stated, "We don't use that type of air freshener." She further stated the SCNA 1 wrote a statement about the incident. The IDON stated a skin assessment was not conducted on the resident because, "I observed her in the dining room and she did not seem in any distress. It was my fault that I didn't check on her." The IDON stated she spoke with CNA 1, who denied the allegation. She further stated, "I trust my CNAs." She said that it was not reported to the Department because, "We don't think it happened." She said that was the extent of the abuse investigation. CNA 1 was not removed from direct patient care and CNA 1 was allowed to continue providing care to Resident A and other residents.CNA 1 was interviewed on 5/17/12 at 10:30 A.M. CNA 1 stated that the IDON asked him if he sprayed Resident A with air freshener. CNA 1 stated, "I don't do that. We have good wipes." CNA 1 stated that he continued to care for the resident until the end of his shift at 2:30 P.M., and for the, "Next day or two days" he continued to take care of Resident A.On 6/13/12 at 9:30 A.M., a review of CNA 1's assignment sheet from 3/15/12 until 4/9/12 confirmed CNA 1 continued to care for Resident A until the resident was moved on 4/9/12.SCNA 1 was interviewed on 5/18/12 at 9:50 A.M. SCNA 1 stated that she was assigned to work with CNA 1 on 3/15/12. SCNA 1 stated that both she and CNA 1 changed the resident's incontinent brief. She said that CNA 1 grabbed a pump bottle off the bedside table and sprayed, "Five or six sprays on her [Resident A's] private parts and then he [CNA 1] unscrewed the bottle and poured it on her [Resident A]." SCNA 1 stated she asked CNA 1, "What are you doing. He said, 'It smells in here'. I slapped his hand away and he told me in Tagalog, 'You're on your own' and left the room. I reported it to my Nursing Instructor right away and she brought me to the DSD office and I told them what happened. They asked me to go get the bottle and I brought it back to them. Then they told me to write what happened, and I did." The Ombudsman was interviewed on 5/29/12 at 3:30 P.M. The Ombudsman stated he visited the facility on 4/23/12 at 9 A.M. and spoke with the IDON and Director of Social Work about the alleged incident of abuse towards Resident A. He further stated, "I made it very clear to them they needed to report the incident to the [Department]."The Nursing Instructor was interviewed on 5/29/12 at 5 P.M. The Instructor stated that the SCNA 1 told her that CNA 1 took a bottle of air freshener and poured it on Resident A's private parts. The Instructor stated that she took SCNA 1 to the IDON and DSD. She further stated that she looked in the supply cabinet and saw the same type bottle of air freshener that SCNA 1 said CNA 1 used on the resident's genitals. The Instructor stated that when she followed up with the DSD later that day or the next day, the DSD told her the air freshener, "Shouldn't have been in the supply cabinet and she was going to make sure it wouldn't be there anymore." The medical record for Resident A was reviewed on 5/17/12. There was no documentation that a physical or skin assessment was conducted on the resident on 3/15/12, after the allegation of abuse was made. There was no documentation that the physician or Responsible Party was notified. There was, in fact, no documentation in the medical record of the allegation of abuse at all. The facility could not provide documentation of an assessment conducted on the resident. The Administrator was interviewed on 6/13/12 at 8:15 A.M. The Administrator stated she was not aware of the abuse allegation until she spoke with the Director of Human Resources (HR) on 4/20/12. The Administrator further stated, "Of course I want to know. They should have taken it more seriously." According to the facility policy and procedure titled, Resident Abuse, Neglect, or Mistreatment, revised 9/1/10, "Any alleged violation involving mistreatment...of a resident shall be immediately reported to the Administrator...who will in turn report the allegation within 24 hours of occurrence to [state agency]... The Director of Nurses/Abuse Prevention Coordinator ...shall thoroughly investigate all allegations... The Supervisor will be responsible for...assessing the resident for identifying events... Assess the resident for signs of physical abuse...Notify the resident's representative and Physician immediately...The Director of Nurses/Abuse Prevention Coordinator...will take steps to ensure and prevent further potential abuse while the investigation is in process... If the accused is an employee of the facility, the HR (Human Resource) Director shall be contacted and become part of the investigation process. The accused employee shall be removed from resident contact..." 2. Resident B, a 96 year-old female, was admitted to the facility on 1/19/11 with diagnoses that included dementia, according to the Record of Admission. According to the Minimum Data Set (MDS) assessment dated 1/13/12, the facility assessed Resident B with moderately impaired cognitive skills, and short and long term memory problems.Resident B was totally dependent on staff for bathing, transfers, dressing, eating, toilet use and personal hygiene. Resident B was unable to walk and used a wheelchair for mobility. Resident B was observed in the Activity Room on 6/13/12 at 9:30 A.M. sitting in a wheelchair with her eyes closed. Resident B did not respond or open her eyes when addressed. Student Certified Nursing Assistant (SCNA) 1 was interviewed on 5/18/12 at 9:50 A.M. She stated that on 3/15/12 she observed Certified Nursing Assistant (CNA) 2 lying on Resident B's bed. SCNA 1 stated two of her classmates reported this incident to the Nursing Instructor.The Nursing Instructor was interviewed on 5/29/12 at 5 P.M. The Instructor stated that two Student Certified Nursing Assistants (SCNA 2 and SCNA 3) reported to her on 3/15/12 that CNA 2, "Was not being appropriate." She stated the student told her CNA 2 was, "Lying on a patient's bed and shoveling food in her (the residents) mouth." The Instructor further stated that SCNA 2 and SCNA 3 told her that CNA 2, "Was not patient and did not have a good attitude with feeding." The Instructor stated she informed the Interim Director of Nursing (IDON) and the Director of Staff Development (DSD) of the student's complaints on 3/15/12. CNA 2 was interviewed on 6/12/12 at 2:35 P.M. CNA 2 stated that she had been falsely accused, by two student CNAs, of force feeding Resident 2. CNA 2 stated that she continued to work freely throughout the facility until the IDON, DSD and Director of Human Resources (DHR) called her in the DHRs office towards the end of her shift, and fired her. CNA 2 further stated that she fed Resident B on a number of occasions while working in the dining room, and was told by the facility to, "Do whatever it takes to get them (the residents) to eat." CNA 2's employee file was reviewed on 6/13/12. According to a handwritten note, signed by SCNA 2 and dated 3/15/12, "Resident B looked hurt when (CNA 2) forced the spoon into her mouth..." According to a second handwritten note, signed by SCNA 3 and dated 3/15/12, "(CNA 2) instructed me to force (Resident B) to eat by pressing the spoon down forcefully on her bottom lip...Every time she would demonstrate it, (Resident B) would grimace in pain..." The IDON was interviewed on 6/13/12 at 7:45 A.M. The IDON stated that, along with the DSD, two CNA students (SCNA 2 and SCNA 3) came to her office on 3/15/12, sometime before noon. The IDON stated the two SCNA's told her that CNA 2 tried to teach them how to feed Resident B, "By pulling her lip down." The IDON and the DSD went to the DHR and told her to prepare termination papers for CNA 2. The IDON stated she did not conduct any further investigation. Resident B's medical record was reviewed on 6/13/12. According to the licensed nurses' notes on 3/12/12, Resident A had an abrasion on the lower left lip that measured 0.2 centimeters (cm) by 0.3 centimeters and a bruise on the lower lip that measured 0.1 cm by 0.1 cm.According to an Interdisciplinary (IDT) note dated 3/14/12 and authored by the IDON, the IDT met, "To discuss bruise and abrasion on L (left) lower lip, she is unable to relate what happen..." The IDON acknowledged that the IDT note, "Kind of ties in with the whole thing." The IDON stated she did not assess Resident B for injury. There was no documentation that the facility notified the physician or responsible party that the abrasion and bruise sustained by Resident B may have been the result of forced feeding by CNA 2. The IDON further stated, "If it occurred, it was abuse. I can't tell you why I did or didn't notify you (Department)."The Administrator stated on 6/13/12 at 8:25 A.M. that force feeding was, "A very strong allegation. I would have wanted them to report it to the State. We should have handled it better." According to the facility policy and procedure titled, Resident Abuse, Neglect, or Mistreatment, revised 9/1/10, "Any alleged violation involving mistreatment...of a resident shall be immediately reported to the Administrator...who will in turn report the allegation within 24 hours of occurrence to [state agency]... The Director of Nurses/Abuse Prevention Coordinator ...shall thoroughly investigate all allegations... The Supervisor will be responsible for...assessing the resident for identifying events... Assess the resident for signs of physical abuse...Notify the resident's representative and Physician immediately...The Director of Nurses/Abuse Prevention Coordinator...will take steps to ensure and prevent further potential abuse while the investigation is in process... If the accused is an employee of the facility, the HR (Human Resource) Director shall be contacted and become part of the investigation process. The accused employee shall be removed from resident contact..." The facility failed to follow their policies and procedures after two allegations of abuse were made. The facility failed to ensure thorough investigations were conducted; failed to ensure the CNA's were removed from direct patient care during the investigations; failed to promptly assess each resident for injuries; failed to ensure the responsible parties and physicians were notified; and failed to ensure the abuse allegations were reported to the Department within 24 hours. As a result, the facility failed to protect Resident A and Resident B by allowing the alleged abusers to continue to care for both residents and other residents unsupervised within the facility. The result of these failures had a direct relationship to the health, safety and security of patients. |
| 080000962 |
THE SPRINGS AT PACIFIC REGENT |
080011803 |
B |
03-Nov-15 |
D2BQ11 |
7856 |
Citation Text for Tag 0225, Regulation FF09 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 to the Department within 24 hours an allegation of sexual abuse, when Resident B (a male) walked into Resident A's room (a female), told her to be quiet, lifted her gown and placed his head close to her private area. The facility also failed to investigate the allegation until Resident A notified the Ombudsman about 56 hours after the incident occurred. As a result, Resident A said she felt like she was not important enough for the staff to discuss the incident with her and she did not feel safe with Resident B in the building. Resident A said since no staff took action she phoned the Ombudsman on 8/10/15, (2.5 days after the incident) herself.Findings: Resident A, a 66 year old female was admitted to the facility on 7/28/15 with diagnoses to include fractured lower leg and fractured arm, per the Admission Record. Resident A was her own responsible party and had full capacity to direct her own care per the Admission Record. Resident B, a 61 year old male was admitted to the facility on 8/5/15 per the Admission Record.On 8/12/15 at 9:40 A.M., Resident A was interviewed in her room. Resident A was in a private room, in the last room at the end of the hallway. Resident A said on early Saturday morning (8/8/15) about 1 A.M., she was in her bed in her room. Resident A said she liked to have the door to her room closed and it was closed that night. Resident A also said she always felt hot at night and slept in a hospital type gown, and did not like sheets or other covers on top of her. Resident A said she saw the door to her room open and began to ask who entered her room. She said she saw a shadowed figure enter the room, and close the door. Resident A then said, "What's happening?" The shadowed figure, (Resident B) said, "You know what I want, sh, be quiet." Resident A said Resident B continued towards her, lifted her gown and Resident B put his head down towards her "private" area. Resident A said, she snatched away her gown, swung her legs over the edge of the bed, and exited into the hallway past Resident B and began screaming for help. Resident A said Certified Nursing Assistant (CNA) 1 held her as she was leaning against the wall. Resident A said CNA 1 asked her, what was wrong. Resident A said she told CNA 1, there was a man in her room.Resident A said Licensed Nurse (LN) 2 arrived within seconds after CNA 1 and she told him there was a man in her room.LN 2 said on 8/13/15 at 6:40 A.M., he worked the night of 8/8/15. LN 2 said he heard Resident A call for help and saw Resident A in the hallway. Per LN 2, Resident A kept saying, "There's a man in my room." LN 2 said he instructed CNA 1 to take Resident A to the nurse's station and stay with her.LN 2 said he went to Resident A's room and LN 2 saw Resident B about half way between the door and the bed in the room. When LN 2 asked Resident B what he was doing in the room, he said, "I'm not in my room?" On 8/13/15 at 6:45 A. M., LN 2 and CNA 1 were interviewed. Both said Resident A was, "shaking" and "breathing rapidly." They said, "She was scared." They both said Resident A kept repeating, "He lifted my gown and said, be quiet." LN 2 said after Resident A told him what happened in her room, he immediately phoned the Administrator (ADM) and recorded the time as 12:48 A.M. The ADM called backed within a few minutes. LN 2 said, he told the ADM, "I need advice, a male patient wandered into a female room and she alleged he touched her. Do I need to call the police? What should I do?" LN 2 said the ADM told him he would take care of it, when he came in. LN 2 said he was not instructed to make any other phone calls. The treating physician (MD) 1 for Resident A was interviewed on 8/12/15 at 12:15 P.M. at the facility. MD 1 said he made rounds on Resident A on Monday (8/10/15) and Resident A told him of the incident. Resident A told MD 1 she was scared. MD 1 said he told the ADM to phone the police, this was an assault.Resident A said during her interview on 8/12/15 at 9:40 A.M, she phoned the Ombudsman (a public advocate) on Monday (8/10/15) about 9 A.M., and the Ombudsman came to the facility and interviewed her that afternoon. Resident A said she told the Ombudsman about the incident and she said she was still afraid of Resident B.The Ombudsman was interviewed by phone on 8/12/15 at 2:24 P.M. She said Resident A told her, "There was a man in my room." The Ombudsman said she asked the ADM on 8/10/15 if he had called the police. The ADM told her he did not think he needed to report the incident.The ADM said, on 8/12/15 at 7:55 A.M., he did not phone the police until 8/10/15, after he talked with the physician and the Ombudsman about the abuse allegation.The ADM said on 8/12/15 at 7:55 A.M., he was the abuse coordinator, but he did not know he was supposed to make sure the physician, the family, the Department, and the Ombudsman were notified within 24 hours.The ADM said he did not come in to the facility on 8/8/15, or 8/9/15 and he did not speak to Resident A until 8/10/15 (Monday) afternoon, after the Ombudsman spoke with him.Resident A sat in her wheelchair in the hallway outside of therapy on the first floor on 8/13/15 at 11 A.M. The DON was also present. Resident A said she did not feel the facility protected her after the incident. She said no one from the facility spoke to me on Saturday or Sunday. She said that made her feel like she was "burdensome" and "not credible."Resident A also said when she finally talked to the ADM on 8/11/15; she did not feel like her concerns were heard. Resident A said the first person she talked to was the Ombudsman on Monday afternoon (8/10/15), over 2 days after the incident. Resident A said she did not believe the facility followed the mandatory steps to protect her and report the incident.The facility policy, titled Resident Assessment, Abuse Program, dated 5/2015, was jointly reviewed with the ADM, on 8/13/15.The ADM said he did not follow the facility policy for reporting, Sexual Abuse: this includes, but is not limited to sexual harassment, sexual coercion or sexual assault" ...4. "Covered individual must report any "reasonable suspicion" of a crime that does not involve "serious bodily injury" to all the following entities within 24 hours of observing, obtaining knowledge of or suspecting physical abuse: Local law enforcement...Department of Public Health..Local Ombudsman." |
| 010001007 |
The Redwoods, A Community of Seniors |
110009576 |
B |
20-Nov-12 |
None |
9100 |
1418.21(a)(1)(A) Health & Safety 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 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 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 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 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 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 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 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 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 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 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 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 and interview, the facility failed to post the overall facility rating in the specified fonts, and in the specified locations, which resulted in the information being unavailable and unreadable by residents, staff and the public. Findings: During the initial tour on 10/9/12, at 9:45 a.m., no posting of the overall facility star rating was seen in the skilled nursing facility hallways, dining areas, employee break room, activities room, or any other area accessible and visible to members of the public. On 10/9/12, at 3:40 p.m., no facility star rating information was observed in any of the resident dining areas or employee break room. During subsequent observations on 10/11/12 at 1:30 p.m., 4 p.m., and 4:55 p.m. and 10/12/12 at 2 p.m., no facility star rating information was posted in any of the skilled nursing facility's rooms utilized for common functions or in the hallways or in the employee lounge. In an interview at 2:15 p.m., on 10/12/12, Administrative Staff A stated she was not aware of the specific requirements for the star rating posting. |
| 110000760 |
The Meadows of Napa Valley Care Center |
110011290 |
A |
08-Jul-15 |
D0FY11 |
6046 |
? 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 falls for Resident 9 with a history of multiple falls, when staff left the resident unattended in the restroom. This failure resulted in Resident 9 sustaining a fall with a hip fracture.Review of Resident 9's facesheet (a patient summary sheet which includes contact details, and a brief medical history), indicated Resident 9 was admitted on 1/10/14, for rehabilitation care with multiple diagnoses which included congestive heart failure (occurs when your heart does not pump blood as well as it should) and acute kidney failure. During an interview, on 3/6/14 at 1:13 p.m., Licensed Staff T stated Resident 9 used the recliner with tab alarm (features a pull string that attaches magnetically with garment clip to the resident. When the resident attempts to rise out of the chair the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the caregiver) and pad alarm (a quick alert pressure-sensing safety alarm placed on the resident's bed, wheelchair seat or recliner which alerts when the resident attempts to rise out of the chair or bed). Review of Resident 9's MDS (Minimum Data Set, an assessment tool) admission assessment, dated 1/17/14, the functional status indicated Resident 9 required limited assistance with bed mobility, transfer, ambulation, dressing, toilet use and personal hygiene.Review of Nurses Notes, dated 2/8/14 at 12:25 a.m., indicated Resident 9 had a fall from the recliner and incurred a scalp laceration requiring treatment at the emergency room and three staples to close the head wound. New interventions added to the Short Term Care Plan, dated 2/8/14, were to encourage the resident to always call for assistance for transfers, ambulation, and tab alarm in geri-chair (or geriatric chair - a positioning chair, designed to have multiple reclining and upright positions to maximize comfort). A post fall evaluation, dated 2/8/14, of Resident 9's functional status indicated the resident required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with transfers and limited assistance with contact guard assist with ambulation. Assistive devices used by the resident included walker and wheelchair. During an interview, on 2/6/15 at 9:55 a.m., Rehab Director V, when asked to differentiate between stand by assist and contact guard assist, stated with contact guard assist, the residents condition was more declined, which required the caregiver to have a hand on the patient, but not helping. Review of Nurses Notes, dated 2/11/14 at 8:30 a.m., Resident 9 had a second fall in his room and was found sitting on the floor with a skin tear on his left hand. New interventions added to the short term care plan, dated 2/11/14, were for continuous frequent visual check and offer for assist, tab/pad alarm on, non-skid pad placed in the geri chair recliner, continue reminding resident to always call for assistance and call light within reach at all times. A post fall evaluation, dated 2/11/14, of Resident 9's functional status indicated the resident now required one person assist (physical assist) for bed mobility and transfers and required front wheel walker with contact guard assist for ambulation. The post fall evaluation requiring one person assist for bed mobility and transfers and contact guard assist with ambulation was not indicated in the care plan. A Nurses Notes, dated 2/21/14 at 4:45 a.m., indicated Resident 9 had a fall in the bathroom requiring transfer to the acute hospital on 2/21/14 at 5:20 a.m. The Nurses Notes indicated Resident 9 was inside the bathroom with the CNA (certified nurse assistant) helping the resident back in his recliner. The Nurses Notes documented the Resident was standing with his walker, had no signs of distress, no shortness of breath and was stable. The CNA went outside the resident's room to get a blood pressure machine and heard a sound, like the resident fell. The CNA rushed inside the bathroom and noted the resident on the floor lying on his right side and the right forehead with a bleeding wound. "The Resident could not move his right lower extremity and complained of severe pain." Review of a signed statement, dated 2/21/14, Unlicensed Staff U documented he assisted Resident 9 in the bathroom and informed the resident he (CNA) would be checking his (resident's) vital signs and the resident said "OK." Unlicensed Staff U documented he quickly left to get the vital signs machine when he heard the resident yell and a thud. Review of the acute care hospital discharge summary dated 2/23/14, indicated Resident 9 was admitted on 2/21/14, status post fall which resulted in a fractured hip. The resident had multiple diagnoses, was kept on comfort care, and died 2/23/14. Review of the Event Investigation Summary, dated 2/21/14, Management Licensed Staff AF documented Resident 9 continued to require one person assist / supervision with his ADL's (activities of daily living). Management Licensed Staff AF documented it was an avoidable accident, had staff not left the resident to get the BP (blood pressure) cuff. During an interview on 3/6/14 at 3:30 p.m., Management Licensed Staff AF stated it was an avoidable accident, as the CNA left the resident to get the BP machine. The facility failed to ensure adequate supervision to prevent falls for Resident 9 with a history of multiple falls, when staff left the resident unattended in the restroom. This failure resulted in Resident 9 sustaining a fall with a hip fracture. This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010001007 |
The Redwoods, A Community of Seniors |
110011426 |
A |
27-Aug-15 |
BI8P11 |
7808 |
72311(a)(1)(B) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. 72311(a)(2) Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The facility failed to develop a care plan for Resident 1 who had a prior history of falls while being transferred in a wheelchair by staff and failed to implement the care plan for assistive devices while in the wheel chair. These failures resulted in Resident 1's fall from a wheelchair while being transported by staff. Resident 1 sustained a neck fracture which contributed to her decline and death six days after the fall. On 8/12/13 the Department received a report from the facility that Resident 1 fell on 8/10/13 and sustained fracture of the cervical vertebra (neck). Review of Resident 1's admission record facesheet, dated 8/27/13, indicated Resident 1 was a 93 year old female readmitted on 7/23/09 with the diagnoses of failure to thrive, depressive disorder and osteoporosis (decrease in bone mass).Resident 1's MDS (Minimum Data Set, an assessment tool), dated 6/25/13, indicated Resident 1's cognitive skills for daily living was severely impaired. The MDS also noted Resident 1 needed extensive assistance for her activities of daily living. The facility's "Fall Risk Assessment" dated 10/2/12, 12/31/12, 4/10/13 and 7/8/13, documented Resident 1 was a high fall risk. Review of a "Post Fall Review" dated 2/28/13, documented Resident 1 had a fall on 2/28/13 when Resident 1 fell from her wheelchair while being pushed by a CNA (certified nursing assistant). Resident 1 sustained a head laceration and hip pain during that fall. The IDT (Inter Disciplinary Team) intervention indicated to ensure that Resident 1's legs were uncrossed with both feet on the foot pedals before moving Resident 1 in her wheelchair so Resident 1 would not lose her balance. Additional interventions included to obtain a wedge cushion for the seat of the wheelchair and for Rehabilitation to look into a high back reclining wheelchair for Resident 1.During an interview on 9/18/14 at 11:20 a.m., Physical Therapist C stated it was a common practice in the facility to assess residents who were high risks for falls to determine if they could be placed in a high back reclining wheelchair and to provide them with a wedge cushion. Physical Therapist C stated the wedge cushion was to be placed on the seat of the wheelchair. She stated a wedge cushion was thicker in front and thinner at the back for positioning of the resident, so the resident would not slide forward and fall. During an interview on 8/28/13 at 4:35 p.m., CNA A stated she took Resident 1 back to her bedroom on 8/10/13 when [the second] fall occurred. She stated Resident 1 crossed her legs and tried to uncross her legs but Resident 1 tilted forward and fell out of the wheelchair hitting her head on the floor mat. CNA A stated the incident happened quickly. CNA A stated she asked Resident 1 not to cross her legs and tried to stop Resident 1 from doing it many times in the past. During a follow up interview on 9/23/14 at 10:40 a.m., CNA A stated Resident 1 had foot rests before, but because the resident's skin was sensitive she was told not to use the foot rest. CNA A stated in addition, at the time of the fall, Resident 1's wheelchair was not reclining backward and the wedge cushion was not used.During an interview on 9/10/13 at 11:10 a.m., Licensed Staff B stated the foot rest of the wheelchair was removed because of skin abrasions on the legs and Resident 1's feet could entangle on the foot rest. During an interview on 9/23/14 at 2:36 p.m., Management Staff D stated the foot rest was removed because Resident 1 put her feet in between the foot rest of the wheel chair and Resident 1 sustained skin abrasions from it. Review of Resident 1's care plan, dated 7/3/12, documented Resident 1 was at risk for injury secondary to falls. Goals included Resident 1 would have no complications from falls, would achieve optimal activity without injury, and risk for injury would be minimized by residents and staff. A handwritten note, dated 2/28/13, documented the intervention to use a wedge cushion in the wheelchair on day shift. There was no documentation that intervention had been discontinued. The fall risk care plan did not include the previous IDT recommendation to ensure the foot pedals would be in place if Resident 1 was transported in the wheelchair. There was no intervention related to Resident 1's history of crossing her legs during transport or removal of the foot rests related to skin break down due to use of footrests. A care plan, dated 8/8/13, for altered skin integrity documented to pad the wheelchair foot rest / mobility device as appropriate. There was no intervention to remove the foot rests due to skin breakdown. Review of Nurses' Notes, dated 8/10/13 at 3:15 p.m., indicated after Resident 1's fall the attending physician ordered Resident 1 sent to the hospital for neck X-ray and CT scan (computerized tomography) of the head. Review of the CT scan, dated 8/10/13 at 5:49 p.m. documented an impression of: 1. Dens Fracture. (Fracture of the vertebra of the neck) 2. One and possibly two non- displaced fractures of C1 (First vertebra of the neck) Review of an emergency room physician consultation note, dated 8/10/13, from the acute care hospital indicated the physician had a discussion with Resident 1's family that the type of fracture sustained by Resident 1 was definitely of unstable type, which could slip and cause fatal cord compression and likely would not heal without surgical fusion. The record noted Resident 1's family member opposed the major spine surgery and the physician agreed with the family's decision. The record further indicated to prevent major movement of this fracture Resident 1 would require a hard [neck] collar for life. Review of the Hospice Initial Certification, signed by Resident 1's physician on 8/12/13, documented Resident 1 was admitted to hospice on 8/11/13. The primary Hospice issue was dementia, complicated by recent trauma, fall with fracture of the neck. Review of Resident 1's face sheet documented Resident 1 expired in the facility on 8/16/13 at 1:15 a.m.Review of the facility's policy and procedure for resident accident and incidents, dated 6/7/13, documented , "The facility will identify each resident at risk for accidents and falls, will adequately plan care for these residents, and will implement procedures to prevent injury related to accidents in the event of an incident, each incident will be documented, investigated, and reported by the IDT team with implementation of new preventative interventions to prevent similar incidents from re-occurring. The facility failed to develop a care plan for Resident 1 who had a prior history of falls while being transferred in a wheelchair by staff and failed to implement the care plan for assistive devices while in the wheel chair. These failures resulted in Resident 1's fall from a wheelchair while being transported by staff. Resident 1 sustained a neck fracture which contributed to her decline and death six days after the fall. The above violations presented either imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result |
| 010001007 |
The Redwoods, A Community of Seniors |
110011502 |
B |
27-Aug-15 |
BI8P11 |
4241 |
72523(c)(2)(A) Patient Care Policies and Procedures (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (A) A current nursing procedure manual. This RULE is not met as evidenced by : The facility failed to implement the Nursing Services policy and procedure for fall with a possible head injury for one resident (Resident 1), when Resident 1 was transferred to bed by staff without the use of a device to immobilize the neck and head after a fall. Resident 1 sustained a neck fracture and the potential for further injury. On 8/12/13, the Department received a report from the facility that Resident 1 fell on 8/10/13 and sustained fracture of the cervical vertebra (neck). Review of Resident 1's face sheet indicated Resident 1 was admitted with the diagnoses of failure to thrive, depressive disorder and osteoporosis. Resident 1's MDS (Minimum Data Set, an assessment tool) dated 6/25/13 indicated Resident 1's cognitive skills for daily living was severely impaired. During an interview, on 8/26/13 at 3:50 p.m., Licensed Staff E stated after Resident 1's fall on 8/10/13, Licensed Staff E assessed Resident 1 and found a small bump on the forehead and cold compress was applied. Licensed Staff E stated Resident 1 did not complain of neck pain but only back pain. Licensed Staff E, together with two CNA's, (CNA A and CNA F) transferred Resident 1 from the floor to bed. She stated later on Resident 1 complained of neck pain when Resident 1 was already in bed. Licensed Staff E stated when paramedics came; the paramedics put a neck collar on Resident 1. During an interview, on 8/28/13 at 4:35 p.m., CNA A stated she took Resident 1 back to her bedroom on 8/10/13 when the fall occurred. She stated Resident 1 crossed her legs and tried to uncross her legs but Resident 1 tilted forward and fell out of the wheelchair hitting her head on the floor mat. CNA A stated the incident happened quickly. CNA A stated she asked Resident 1 not to cross her legs and tried to stop Resident 1 from doing it many times in the past. During an interview, on 9/30/14 at 9:30 a.m., Management Staff D stated if there was a fall with a potential head injury, it was the policy of the facility not to move the resident and call 911.During an interview, on 10/6/14 at 8:30 a.m., CNA A stated after the assessment was done by Licensed Staff E after the fall on 8/10/13, Resident 1 was transferred to bed. CNA A stated Resident 1 was already in bed when she complained of neck pain. The facility provided a written statement completed by CNA A, dated 8/13/13, which documented, "The nurse came to do the assessment, so she said we have to get her off the floor and put her in the bed. The nurse and I shouldn't have pick [sic] her up from the floor but since my adrenaline was too fast my reaction came in second to pick her up from the floor knowing that or thought I was doing a better job at helping her, my worst worries came to reality but there's no way to [sic] could prevent this accident from happening." Review of the facility's Health Care Nursing Policies and Procedures, indicated it was the policy of the facility to use the Lippincott Manual of Nursing Practice Tenth Edition as the basic nursing policy and procedure guideline for the care of the residents of the Health Care Center. The procedure referred to the Lippincott Manual of Nursing Practice Tenth Edition for policies and procedures not addressed in the HCC policy and procedure manual. Review of the Lippincott Manual of Nursing Practice Tenth Edition, documented any person with a head or a back injury should be suspected of having a potential head injury until proven otherwise and to provide immediate immobilization of the spine. The facility failed to implement the Nursing Services policy and procedure for fall with a possible head injury for one resident (Resident 1), when Resident 1 was transferred to bed by staff without the use of a device to immobilize the neck and head after a fall. Resident 1 sustained a neck fracture and the potential for further injury. This had a direct or immediate relationship to the health, safety, or security of patients. |
| 010000985 |
THE TAMALPAIS |
110012664 |
B |
12-Dec-16 |
NYYG11 |
4887 |
T22 DIV5 CH3 ART3-72311(a)(2) (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. This RULE: is not met as evidenced by: The facility violated the regulation by failing to use a gait belt, or two persons physical assist and to use additional assist as needed to ensure a safe transfer for Resident 1, who required two persons physical assist according to the nursing assessment and the falls care plan. This failure resulted in Resident 1 receiving one person assist without a gait belt and falling to the floor fracturing the left hip. The demographic record dated 12/12/13 indicated Resident 1 was a XXXXXXX year old male, admitted to the facility on xxxxxxx, with pain in the limb, cerebral (Latin for brain) degeneration and osteoarthritis (most common chronic condition of the joints), and anemia (a condition in which the blood does not have enough healthy red blood cells). The Fall Risk Assessment dated 6/27/15, indicated Resident 1 scored 10. A score of 10 or more indicates high risk for falls. The quarterly MDS, (an assessment tool) dated 6/16/15, indicated Resident 1 needed extensive assistance (two persons physical assist) for bed mobility, transfer and toilet use. The Falls Care Plan dated 3/20/15, indicated Resident 1 needed extensive assist and gait belt for all transfers. The falls care plan indicated to use additional assist as needed when Resident 1 is not feeling well, feeling weak or dizzy. Device for transfer, mechanical lift as needed. Observe for and educate on proper technique and use of device. During a telephone interview on 8/23/16 at 3:35 p.m., the MDS Coordinator when asked why extensive assistance was not specifically written as two persons physical assist in the falls care plan, she stated, "It is subjective assessment by the CNA (certified nursing assistant) to report to the licensed nurse or another CNA and requesting a second person assist." Interdisciplinary Notes dated 7/6/15 at 4:56 p.m., late entry for 7/5/15 indicated Licensed Staff I was summoned by Unlicensed Staff E to Resident 1's bathroom to find Resident 1 on the floor lying on his back and complaining of pain on his left leg. Interdisciplinary Notes dated 7/6/15 at 10:12 p.m., late entry for 7/5/15, indicated Resident 1 transferred to an acute hospital by ambulance per physician order at 3:45 p.m. During an interview on 7/31/15 at 2:12 p.m., Unlicensed Staff E stated, [Resident 1] was very weak on Sunday, 7/5/15 at 9:30 a.m. when she got him up from bed that morning. Unlicensed Staff E used the sit/stand (standing and raising aid) lift for the first time to get [Resident 1] out of bed to sit in a wheelchair for lunch. At 1:30 p.m., [Resident 1] called for help to go to the bathroom. Unlicensed Staff E pushed [Resident 1's] wheelchair into the bathroom and helped him up but [Resident 1] was saying he wanted to sit down. [Resident 1] was not near enough the commode chair. Unlicensed Staff E was able to push him a little closer to the commode, but it was not near enough. [Resident 1] grabbed the door knob of the adjoining bathroom door which opened and made [Resident 1] go further before he was down on the floor. Unlicensed Staff E pulled the string to the call light in the bathroom when they were both down on the floor. Unlicensed Staff E, when asked why she did not call for help stated, "I did not think of calling for help at that time because [Resident 1] was almost at the commode." In a follow up interview on 8/8/16 at 9:35 a.m., Unlicensed Staff E, when asked if she used a gait belt stated, "No gait belt. I forgot to use a gait belt." During an interview on 8/9/16 at 10:52 a.m., Occupational Therapist J stated if a resident cannot do a two-step (stand and pivot), "I will roll out the commode into the room where there is more space and roll back the commode into the bathroom." The acute hospital admission history and physical indicated Resident 1 was admitted on 7/5/15 at 6:52 p.m. for a severely left comminuted proximal, middle and distal femoral shaft fracture dislodged the tip of the femoral component. The Discharge Summary dated 7/13/15 indicated Resident 1 had a total left hip replacement with removal of implant. Resident 1 required 6 units of packed red blood cells and 3 units of fresh frozen plasma due to hemorrhagic shock and Resident 1 was admitted to intensive care. The facility violated the regulation by failing to use a gait belt, or two persons physical assist and to use additional assist as needed to ensure a safe transfer for Resident 1, who required two persons physical assist according to the nursing assessment and the falls care plan. This failure resulted in Resident 1 receiving one person assist and falling to the floor fracturing the left hip. |
| 010001007 |
The Redwoods, A Community of Seniors |
110012861 |
A |
6-Feb-17 |
2S1G11 |
16991 |
F-323 ?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 6, who had a history of falls, received adequate supervision and assistance to prevent accidents. Resident 6 propelled her wheelchair away from the nurses? station, unnoticed by staff, and fell in the doorway of her room. Resident 6 sustained an extension of the right hip fracture that was surgically repaired approximately two months prior. A second hip surgery was required at the acute care hospital.
Review of Resident 6's face sheet (admission record), undated, documented Resident 6 was XXXXXXX years old, admitted to the facility on XXXXXXX16. The face sheet noted Resident 6 had multiple active diagnoses including a fracture of the ulna (the thinner and longer of the two bones in the forearm, on the side opposite to the thumb), a fracture of right neck of the femur (long thigh bone meeting at the hip), dementia (a disorder of the mental processes marked by memory disorders, personality changes, and impaired reasoning), anxiety, depression, hypertension (high blood pressure), and atrial fibrillation (an abnormal, irregular heart rhythm).
Resident 6's Minimum Data Set (MDS - an assessment tool), dated 2/29/16, indicated a Brief Interview for Mental Status (BIMS) score of "3" (scores of 0 to 7 denoted severe cognitive impairment.) Functional Status, indicated Resident 6 was not yet ambulating (walking) and required extensive assistance, with two staff members, for transfers (bed to wheelchair, wheelchair to toilet.) A subsequent MDS assessment, dated 3/21/16, documented Resident 6's BIMS score remained at "3." Resident 6's transfer ability, indicated she had improved to the point of requiring limited assistance (staff provided guided maneuvering of limbs or other non-weight bearing assistance) for transfers with one staff member present. The MDS cognitive assessment, dated 10/18/16, indicated Resident 6's BIMS score remained at "3."
Review of the facility's "Fall Risk Assessment," for Resident 6, dated 2/22/16, indicated Resident 6 had a total score of 15. A score of 10 or more indicated high risk for falls. The assessment further indicated: Resident 6 had intermittent confusion, history of 1-2 falls in the prior three months, balance problems while standing and walking, and did not consistently use assistive devices (walker, wheelchair, cane). The fall assessment documented Resident 6 had taken or currently took the following medications within the previous seven days: antihypertensives (lowers blood pressure), anesthetics (a drug used to prevent pain during surgery), benzodiazepines (sedatives generally used for anxiety and/or sleep problems), and antidepressants (drugs used to treat depression).
A subsequent Fall Risk Assessment, dated 4/4/16, at 8:14 p.m., had a score of 13. Review of the facility's "Charge Nurse Rounds Report," with the residents' fall risk scores, indicated, on 5/2/16, Resident 6 had an increased score of 17. On 7/18/16, the fall risk score rose to 21.
The Care Plan for the prevention of falls, dated 2/22/16, indicated Resident 6 had risk factors that required monitoring and intervention to reduce potential for falls. Risk factors included, "Altered mental status as evidenced by confusion." The goal of the Care Plan was Resident 6 would have no injuries due to falls "with supervision and verbal reminders for better control of risk factors..." The facility's approach (interventions) to reduce the potential for falls was to, "attempt to anticipate needs - toileting, hydration...before Resident attempts to fulfill on own; bring [Resident 6] to the nurse's station when out of bed for observation; require 1-2 persons to assist with all transfers; and encourage Resident to sit in areas well supervised by staff." Updated approaches, dated 3/29/16, after a fall to the floor next to her bed on 3/28/16, included, "visual checks of resident every two hours; position [Resident 6] near the nurse's station for increase (sic) visibility." After another fall on 6/28/16, interventions were to place Resident 6 at the nurse's station or in the activity room for increased visibility and monitor resident's whereabouts. After another fall on 7/12/16, interventions dated 7/28/16, were to monitor Resident 6's activity with frequent checks for safety, bring to common areas to avoid being left alone, and "provide 1:1 sitter as appropriate."
Review of the Interdisciplinary Notes, dated 2/23/16 at 5:31 p.m., indicated Resident 6 "...needs constant supervision...is very impulsive and is a high risk for fall." Resident 6's Care Plan, dated 2/22/16 and 3/29/16 did not indicate a plan to provide "constant supervision."
During an interview on 4/21/16 at 11:30 a.m., Licensed Staff D stated Resident 6 was confused when admitted to the facility in February 2016. Resident 6's family provided a daytime sitter to accompany the resident. At night, the facility provided a sitter from a homecare agency. Interdisciplinary Notes dated 2/23/16, at 5:31 p.m., indicated Resident 6 was provided a "one on one sitter" for being "very impulsive" and a high risk for falls. Resident 6's Care Plan did not document the addition of a sitter.
Review of attendance records from a private homecare company, indicated Resident 6 had a sitter for 12-hour shifts, generally from 6 p.m. to 6 a.m. or 8 p.m. to 8 a.m., starting on 2/22/16. There was no attendance record of a sitter after 3/21/16. During a concurrent interview, on 4/21/16, at 2 p.m., Licensed Staff D stated, approximately one week before 3/28/16, there was no longer a sitter, "Because she had cleared," (confusion had diminished.) There was no documentation of a nursing assessment that indicated Resident 6's decrease in confusion or evaluation of need for a sitter. A licensed nurse's note dated 3/21/16, at 10:33 p.m., indicated Resident 6 was alert "with confusion."
Licensed nurse?s notes, dated 3/27/16 at 7:37 a.m., indicated Resident 6 was confused and tried to get out of bed and dislodged her urinary catheter (a thin sterile tube inserted into the bladder to drain urine.)
A nurse?s note, dated 3/27/16, at 10:39 p.m., indicated Resident 6 had increased agitation and kept wanting to get out of bed. Confusion was noted and Resident 6 was placed in her wheelchair during the shift. A clip alarm (an alarm unit placed on a resident's wheelchair and clipped to the resident's clothing which activates an alarm if the resident attempts to get up from the wheelchair unassisted) was "in place."
Licensed nurses notes, dated 3/28/16 at 7:31 a.m., indicated Resident 6 had an unwitnessed fall at 6:30 a.m. Resident 6 was found sitting on the floor next to her bed, "confused and highly impulsive" and had mild pain to her right hip. The licensed nurse noted there was no apparent injury or bruising and the resident was able to move her extremities (arms/legs) without difficulty.
Licensed nurse?s notes, dated 4/4/16, contained the following documentation:
On 4/4/16 at 4 a.m., Resident 6, "...continues to be confused...Fall precautions maintained. Bed low. Alarms in place." The nursing note at 2:43 p.m. documented , "...resident had been agitated during the day."
On 4/4/16 at 10:25 p.m., Licensed Staff H documented Resident 6 had an unwitnessed fall at 7:45 p.m. No injury or bruising was identified, however, Resident 6 "complained of moderate to severe right hip pain, unrelieved by Tylenol (pain reliever)...alternating with Tramadol" (a narcotic pain medication used to treat moderate to severe pain.) Additionally, the nurse's note indicated Resident 6 remained agitated and continued to ask to be toileted. Resident 6's doctor and family were informed of the fall, and Resident 6 was monitored every 30 minutes during the shift.
Review of the acute care hospital's discharge summary, dated 4/12/16, indicated Resident 6 was at [the facility] when she tried to get up on her own and had a ground level fall. Resident 6 sustained a right periprosthetic (around the components and/or implants of her hip surgery in February 2016) hip fracture. Resident 6 was admitted to the hospital on XXXXXXX16. On 4/8/16, Resident 6 underwent another right hip surgery to repair the new fracture.
During the interview on 4/21/16 at 11:30 a.m., Licensed Staff D stated Resident 6 had an unwitnessed fall the evening of 4/4/16. Resident 6's physician ordered an X-ray of her right hip which appeared "normal." Licensed Staff D stated Resident 6 continued to have right hip pain after the fall, unrelieved by pain medication. A follow-up office visit to Resident 6's surgeon, on 4/7/16, (to examine the resident after the original hip surgery in February) revealed an extension of the repaired right hip fracture.
During an interview on 4/21/16 at 3:10 p.m., Unlicensed Staff K stated she was assigned to care for Resident 6 on the P.M. shift (3-11 p.m.) on 4/4/16. Unlicensed Staff K described Resident 6 as being "agitated" since admission and was "a fall risk." Unlicensed Staff K stated, on 4/4/16 between 5 and 6 p.m., she took Resident 6 to the dining room for dinner and Resident 6 was "shouting" telling people to take her home and saying, "Who's coming for me?'" Unlicensed Staff K stated, between 6 and 7 p.m., Resident 6 wanted to go to the bathroom three times, although she had a urinary catheter. Unlicensed Staff K stated, "I took her to the bathroom though."
Unlicensed Staff K stated, on 4/4/16 at 7:15 p.m., she placed Resident 6, in her wheelchair, at the nurse's station, informed Licensed Staff H and continued caring for other residents. At 7:45 p.m., Unlicensed Staff K stated housekeeping staff found Resident 6 on the floor at the threshold of her room. Unlicensed Staff K stated no one saw her (Resident 6) leave the nurse's station. Unlicensed Staff K stated Resident 6 was found on her back and the clip alarm was "on" (sounding off). Unlicensed Staff K stated five staff members responded to Resident 6's fall. When asked if Resident 6 had pain, Unlicensed Staff K stated, "No, she told the nurse she was ok." For the remainder of the P.M. shift, Unlicensed Staff K stated she sat with Resident 6 and "she (Resident 6) was still yelling out and saying, 'There's a man here,' like she was hallucinating." When asked to describe some of the safety measures the facility implemented for residents at risk for falls, Unlicensed Staff K stated, "room changes, floor mat, call cord (call bell) within reach, bed alarm, clip [alarm]."
During a telephone interview on 4/25/16 at 2:38 p.m., Family Member Q stated Resident 6 had a history of mild to moderate dementia but after hip surgery in February, "With anesthesia and morphine, she became increasingly confused." Family Member Q stated, on 4/4/16 Resident 6 "probably felt like she needed to use the bathroom, took herself there and tried to stand on her own."
During a telephone interview on 4/26/16 at 2:17 p.m., when asked who monitored residents when they were placed at the nurse's station, Licensed Staff D stated the licensed nurse (on duty) "would be there, especially when preparing for med pass (administering medications) but not at all times." Licensed Staff D stated the CNA (Certified Nursing Assistant) "would alert the licensed nurse that a resident is being placed there" while the CNA tends to his/her other residents.
During an interview on 5/2/16 at 12:20 p.m., when asked who monitored Resident 6's whereabouts on the evening of 4/4/16, Licensed Staff D stated, "Staff involved in her care...would have to coordinate, to keep an eye on her."
During a telephone interview on 5/2/16 at 2:20 p.m., Licensed Staff G stated, she responded to Resident 6's fall on 4/4/16 and, "She was on the floor by the time I got there." When asked how residents were monitored at the nurse's station, Licensed Staff G stated, "We're all watching them," and a CNA would tell the nurse if he/she placed a resident at the nurse's station. Licensed Staff G stated Resident 6 did not have a sitter when she fell on 4/4/16.
During a telephone interview on 5/2/16 at 3:53 p.m., Licensed Staff H stated she was assigned to care for Resident 6 on 4/4/16. Licensed Staff H described Resident 6 as being "Very, very agitated, she didn't want to be there," [at the facility]. When asked to describe "agitated," Licensed Staff H stated Resident 6 was very forgetful and repeated over and over "can you help me, I want to go home." Licensed Staff H stated Resident 6 could not recall having just spoken to a family member on the telephone. Licensed Staff H stated Resident 6 was at the nurse's station after dinner and, "I continued my med pass." Licensed Staff H stated the CNA "usually tells me she's (Resident 6) there (at the nurse's station) or I see her there." When asked who supervised Resident 6 at the nurse's station, Licensed Staff H stated, "I go back and forth and I park (place) my cart (medication cart) at the nurse's station and the CNA's walk by her." When asked how long Resident 6 was at the nurse's station, Licensed Staff H stated she did not know and added, "I didn't see her leave the nurse's station...next thing she's on the floor in her room." When asked how she supervised or monitored an agitated and confused resident as Resident 6 was described, Licensed Staff H stated "I assign one CNA to stay with her if there's no sitter available" and kept the bed "very low" and a padded floor mat next to the bed. Licensed Staff H confirmed Resident 6 did not have a 1:1 sitter on the evening of 4/4/16.
During an interview on 10/11/16, at 10:55 a.m., Administrative Staff B stated Resident 6 was on the facility's Falling Star Program. Concurrent review of the facility's Falling Star policy indicated the Falling Star Program was used to remind staff to monitor "high risk" residents for fall prevention and that these residents have interventions in their care plans to reduce and/or prevent repeat falls.
During an interview on 12/13/16 at 12:50 p.m., when asked if Resident 6 had a current 1:1 sitter, Licensed Staff D stated she had a family companion during the day, however, "No sitter, not on a regular basis." When asked how staff "monitored" Resident 6 to prevent falls, Licensed Staff D stated licensed staff and CNA's (certified nurse assistants) made visual checks, placed resident near common areas "if restless," and used a sensor monitor (an alarm that sounds if a resident attempts to get up from bed or wheelchair).
During an observation, on 12/15/16 at 11:55 a.m., in the dining room, Resident 6 sat in a wheelchair alone at the table.
During a telephone interview on 12/19/16 at 9:55 a.m., Licensed Staff D stated Resident 6 had two additional falls on 6/28/16 and 7/12/16.
Review of the facility's policy and procedure titled, Resident Accident and Incident, dated 6/7/13, indicated the purpose of the policy was to ensure each resident...received adequate supervision and assistance to prevent accidents and/or injury..." When a resident was identified as "at risk for falls or accidents," the policy indicated the facility would implement procedures to prevent accidents and injury related to accidents.
Review of the facility's policy and procedure titled, Fall Prevention Program, dated 8/31/15, indicated a resident with a high risk for falls or potential for repeated falls would be "monitored daily for falls and/or lack of falls to determine effectiveness of...interventions..."
The facility failed to ensure Resident 6, who had a history of falls, received adequate supervision and assistance to prevent accidents. Resident 6 propelled her wheelchair away from the nurses? station, unnoticed by staff, and fell in the doorway of her room. Resident 6 sustained an extension of the right hip fracture that was surgically repaired approximately two months prior. A second hip surgery was required at the acute care hospital.
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. |
| 110000760 |
The Meadows of Napa Valley Care Center |
110012915 |
B |
28-Feb-17 |
BJKS11 |
2448 |
Health & 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 notify the State Agency immediately or within 24 hours when a staff reported to the Administrator on 4/4/16 allegations of abuse made by two Residents (Resident 1 and Resident 2). The Administrator did not report these allegations to the Department until 4/14/16. These failures had the potential to place residents at risk for abuse when allegations of abuse are not reported timely.
During a telephone interview on 4/14/16 at 4:35 p.m., the Administrator stated he would be submitting an abuse report to the Department due to care issues related to Certified Nurse Assistant (CNA) B. The Administrator stated on 4/4/16 he had received a report of allegations from Licensed Nurse E regarding CNA B. The Administrator stated Licensed Nurse E told him one resident [Resident 2] had reported feeling "scared to death" of CNA B and did not want to use the call light when that CNA was on duty. The Administrator stated Licensed Nurse E also reported to him at that time another Resident [Resident 1] told Licensed Nurse E that CNA B sprayed her in the face with a shower head and reportedly told the resident that if she did not stand up she would not receive a shower. The Administrator stated that same day he interviewed the residents. He stated the residents did not report concerns of abuse and their stories did not match up to Licensed Nurse E's initial report.
During an interview on 4/15/16 at 2:05 p.m., the Administrator stated he and the DON had not initially suspended CNA B when the allegations of abuse were first reported. He stated after they interviewed the affected residents on 4/4/16 and CNA B they decided it was not abuse and had determined that no abuse had occurred.
The facility failed to notify the State Agency immediately or within 24 hours when a staff reported to the Administrator on 4/4/16 allegations of abuse made by two Residents (Resident 1 and Resident 2). The Administrator did not report these allegations to the Department until 4/14/16. These failures had the potential to place residents at risk for abuse when allegations of abuse are not reported timely. |
| 110000760 |
The Meadows of Napa Valley Care Center |
110012917 |
B |
28-Feb-17 |
T3C111 |
6708 |
F-241 ?483.15 (a) DIGNITY AND RESPECT OF INDIVIDUALITY
?483.15 (a)
The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.
The facility failed to promote care in a manner to enhance dignity and respect for Resident 1, when Certified Nursing Assistant (CNA) A continued to provide incontinent (inability to control bladder) care after Resident 1 told him to stop and stated CNA A was raping her.
This failure resulted in Resident 1 being exposed to continued fear and anxiety. CNA A returned to Resident 1's room later that evening which frightened Resident 1 and which Resident 1 stated made her feel helpless and fear for her safety.
During an interview on 11/2/16 at 8:30 a.m., with the Administrator and Licensed Nurse (LN) B, the Administrator stated Resident 1 had reported to visiting family on 11/1/16, that Certified Nursing Assistant (CNA) A had raped her during the night on 10/31/16. The Administrator stated CNA A had stated, during the facility internal interview, Resident 1 said "stop, you're raping me." The Administrator stated CNA A continued to change the incontinent brief (designed for adult incontinent use) and did not stop and should have when Resident 1 said stop. LN B stated, during an interview with CNA A, CNA A indicated he was just doing his job, that he had to finish changing her. LN B stated, even though Resident 1 clearly told CNA A to stop he did not, and CNA A did not report it to staff on the evening shift (3 p.m. to 11 p.m.). LN B stated upon return from the emergency room with Resident 1 the police officer and LN B asked Resident 1 if she felt safe and Resident 1 indicated she felt safe but had a bad experience.
During an observation and concurrent interview on 11/2/16 at 10:05 a.m., Resident 1 was in bed with Family Member 2 at the bedside. Resident 1 stated on 10/31/16, during the night, while she was asleep, CNA A came into the room and "ripped" the blanket off her and got on top of her and held down her arms. Resident 1 sated she tried to fight him off by hitting CNA A and cried out for help, but no one responded. She stated her roommate was asleep with her hearing aides out so she could not hear and did not respond. Resident 1 stated she felt "helpless, frightened" and that CNA A returned later that night and tried to apologize. She stated she was so frightened and just wanted him away from her. Resident 1 stated she still did not feel safe and it was a "horrible experience, felt so helpless, and it will take a very long time to recover from this." Family Member 2 stated Resident 1 had relayed the same story to her and the social service person who had just finished interviewing Resident 1. Family Member 2 stated even after staff assured Resident 1 that CNA A was not there and only female caregivers would take care of her, Resident 1 continued to state she was afraid and felt helpless. Family Member 2 stated, "its such a shame, she is on hospice" (a program of medical and emotional care for the terminally ill). Family Member 2 also stated Resident 1 kept commenting that it would take a very long time to get over this horrible experience.
During a record review on 11/2/16 at 9:30 a.m., the Emergency Department Report, dated 11/1/16, indicated physician's diagnosis and medical decision: "...Based on the patients presentation to the ER [emergency room] today, the general diagnostic impression is reported assault. At this time I see no obvious life-threatening injuries ... From the emergency department standpoint, the patient is safe for discharge and the rest of the evaluation will be left up to the evaluating officer..."
During an interview on 11/2/16 at 11 a.m., Social Service (SS) C stated Resident 1 had been interviewed about the rape allegation earlier that morning. SS C stated Resident 1 stated CNA A came into the room in the middle of the night while she was sleeping and reported "he raped me." When SS C asked Resident 1 what happened Resident 1 stated he ripped the cover (blanket) off her and got on top of her. When asked how he got on top of her, SS C stated Resident 1 stated he just did, when asked what CNA A was doing Resident 1 told SS C that she was hitting him and he tried to penetrate her and got off her when she kept hitting him. SS C stated that Resident 1 told her that CNA A returned with a handful of Kleenex with poop on them and he changed her diaper. When SS C asked Resident 1 if she was afraid SS C stated Resident 1 stated yes, but not really now.
During a record review, on 11/3/16 at 11:25 a.m., CNA A's documented statement, dated 10/31/16, indicated: "...I told her I need to change you or can I just check if your [sic] dry so that I don't have to change you, then while I'm doing care she said to me you are rapping [sic] me, and I told [Resident 1] I'm just helping you to get change and put pad on her bottom and I'm just doing my job. I did not report this to anybody because I was busy and their [sic] still have a patient to help get on bed so I'm rushing and I did not think about it to report."
During an interview on 1/9/17 at 2:40 p.m., Police Officer D stated the police determined that alleged rape of Resident 1 was "unfounded", and that CNA A did not stop when Resident 1 told him to stop.
Resident 1's annual History and Physical, dated 4/21/16, indicated Resident 1 was enrolled in hospice care for Stage 4 lung cancer. The annual Minimum Data Set (MDS, a resident assessment and evaluation tool), dated 9/12/16, indicated the Brief Interview of Mental Status (BIMS) score of 14 (score of 13-15 indicates cognitively intact).
A Care Plan entitled, "Psychosocial Well-Being" dated 11/2/16, indicated the problem of psychosocial well-being is impaired related to emotional distress and included interventions of provide emotional support, only female caregivers, and Social Services to provide support if feelings of emotional distress.
The facility failed to promote care in a manner to enhance dignity and respect for Resident 1, when Certified Nursing Assistant (CNA) A continued to provide incontinent (inability to control bladder) care after Resident 1 told him to stop and stated CNA A was raping her.
This failure resulted in Resident 1 being exposed to continued fear and anxiety, when staff did not respond to Resident 1's cry for help. CNA A returned to Resident 1's room later that evening which frightened Resident 1and which Resident 1 stated made her feel helpless and fear for her safety.
This had a direct relationship to the health, safety, or security of patients. |
| 010001007 |
The Redwoods, A Community of Seniors |
110012994 |
B |
16-Mar-17 |
2S1G12 |
3344 |
Health & Safety Code 1429(a)(1)(A)(B)(C) & 1429(a)(2)(A)(B)(C)
1429. (a) Each class "AA" and class "A" citation specified in subdivisions (b) and (c) of Section 1424 that is issued, or a copy or copies thereof, shall be prominently posted for 120 days. The citation or copy shall be posted in a place or places in plain view of the patients or residents in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility.
(1) The citation shall be posted in at least the following locations in the facility:
(A) An area accessible and visible to members of the public.
(B) An area used for employee breaks.
(C) An area used by residents for communal functions, such as dining, resident council meetings, or activities.
(a) Each class "AA" and class "A" citation specified in subdivisions (b) and (c) of Section 1424 that is issued, or a copy or copies thereof, shall be prominently posted for 120 days. The citation or copy shall be posted in a place or places in plain view of the patients or residents in the long-term health care facility, persons visiting those patients or residents, and persons who inquire about placement in the facility.
(2) The citation, along with a cover sheet, shall be posted on a white or light-colored sheet of paper, at least 8 1/2 by 11 inches in size, that includes all of the following information:
(A) The full name of the facility, in a clear and easily readable font in at least 28-point type.
(B) The full address of the facility, in a clear and easily
(C) Whether the citation is class "AA" or class "A."
The facility failed to post Class A Citation #11-2813-0012861 that was served to the facility on 2/6/17 in the locations and manner as specified by the Health and Safety Code. This violation resulted in an automatic "B" Citation.
During an observation on 2/14/17 at 9:30 a.m., no citation was observed with other postings on the bulletin board or by the entry door from the parking lot to the skilled nursing facility (SNF).
During an interview on 2/14/17 at 11:45 a.m., the Director of Nursing (DON) was asked if the above citation was posted. The DON referred to a white binder identified as Survey Binder located under the bulletin board in the SNF which contained the recent federal recertification survey results. The binder did not contain the citation. The DON did not respond when asked about posting of the citation.
During observations on 2/14/17 at 2:50 p.m., and 2/15/17 at 10 a.m., no citation was observed posted on any walls within the skilled nursing facility, bulletin board or dining room.
During an observation and concurrent interview on 2/15/17 at 1:05 p.m., the DON was asked if she was aware of the posting requirements for A citations. The DON stated the citation was in the Survey Binder. Located in the survey binder was a copy of the "A" Citation #11-2813-0012861 served to the facility on 2/6/17. The DON confirmed this was the only location in which the Citation was placed and stated she was not aware of the citation posting requirements.
The facility failed to post Class A Citation #11-2813-0012861, served to the facility on 2/6/17 in the locations and manner as specified by the California Health and Safety Code. This violation resulted in an automatic "B" Citation. |
| 120001408 |
Tulare Nursing & Rehabilitation Center |
120009537 |
B |
03-Oct-12 |
LQRG11 |
5005 |
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 notify the Department of Public Health immediately or within 24 hours following an allegation of abuse made by a resident.On February 1, 2011 at 10:15 AM, an unannounced visit was made to investigate an allegation of failure to report abuse in a timely manner, after a resident complained that a facility CNA (Certified Nurse Assistant) was "mean" to her on January 22, 2011 at 3:10 PM and the facility did not notify the California Department of Public Health (CDPH) by phone or fax until Monday February 24, 2011 at 1:24 PM. The clinical record for Resident 1 was reviewed on February 1, 2011 at 11:45 AM. The record revealed the resident was an 81 year old female admitted to the facility January 11, 2011. Admitting diagnoses included end stage renal disease, chronic pain, and depressive disorder. Nurse's note dated January 22, 2011 at 3:10 pm stated, "Writer was called into Resident room by CNA; resident was very upset with her CNA saying that she is very mean to her because she wouldn't help her." The record also indicated when Licensed Vocational Nurse (LVN) 1 arrived in the resident's room, resident rp (responsible party) was also upset indicating to LVN 1 Resident 1 told the rp that a CNA did not like her and was very mean to her.During an interview on February 1, 2011 the facility Social Service Director (SSD) indicated she found out about the allegations made by the Resident 1, that CNA 1 was "very mean to her" on Monday morning, January 24th during a stand up meeting and reported it to CDPH at that time. When asked what the procedure for reporting abuse was at that facility, the SSD indicated the nurse should have called it in immediately.On February 3, 2011 at 11:50 AM during a phone interview LVN 1 stated she was in the dining room at the facility checking food trays when a CNA came into the dining room and "told me I needed to go talk to Resident 1 because she was really upset". LVN 1 stated she went to the room and Resident 1 was crying, Resident 1 then made the claim that no one in the facility liked her; they don't want her here; and the CNA's are mean to her, mentioning CNA 1 by name. LVN 1 stated Resident 1's family member was in the room and told her that CNA 1 was mean to her mom and the family member doesn't want that CNA to take care of Resident 1 any more. LVN 1 also indicated she spoke to the DON (Director of Nursing) regarding the incident the day it happened.During an interview with Family 1 on February 4, 2011 at 12:00 PM, she indicated, upon entering her Resident1's room during a visit on Saturday two weeks ago, Resident 1 was upset and crying. When she asked Resident 1 what was wrong, Resident 1 told Family 1 she called for someone to change her brief and CNA 1, who responded, told her to quit bugging her and to "shut-up". Family 1 stated she told LVN 1, who came into the room, what had been reported to her and that it hurt her to have Resident 1 talked to like that.During an interview with the Nurse Manager (NM) on March 1, 2011 at 11:55 AM she indicated LVN 1 notified her by phone of the incident on Saturday January 22, 2011. The NM stated she did not go to the facility to investigate, just asked about the situation over the phone. NM said LVN 1 told her false accusations had been made by the resident before against the staff. NM stated she told LVN 1 to remove CNA 1 from Resident 1 and change assignments so she would not be caring for Resident 1.During a concurrent interview and record review on March 1, 2011 at 1:05 pm review of the facility policy titled, "Prevention of Abuse", dated April 30, 2009, indicated: ". G. Reporting 1. All mandated reporters are required by law to report incidents on known or suspected abuse in two ways: 1) by telephone within 24 hours to the CDPH, local LTC Ombudsman or the local law enforcement agency." The NM indicated she relied on the staff a lot because she is newly employed and didn't know residents like the staff did. She did not report the incident when it was called to her because at that time she believed the best course of action was to just remove the CNA from caring for that resident. The NM stated she decided on this course of action because of a statement made to her by LVN 1 indicating this was nothing new for this resident. She also indicated the IDT (Inter-disciplinary team) reviewed the statement made by Resident 1 on Monday January 24 and felt it needed to be reported, so they filled out the SOC 341 and reported it to the CDPH, but the NM was indicated she was not involved in that meeting. The violation of this regulation had a direct or immediate relationship to the health, safety or security of residents. Failure to comply with the requirements of this section shall be a class "B" violation. |
| 120000328 |
The Rehabilitation Center of Bakersfield |
120010345 |
B |
16-Jan-14 |
L7EZ11 |
3030 |
T22 72311(a)(1)(A) Nursing service shall include, but not be limited to, the following: Planning of patient care, which shall include at least the following: Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. On 9/15/10, an unannounced visit was made to the facility to investigate an entity reported incident regarding Patient A's fractured foot. Based on record review and interview, the facility failed to ensure Patient A's wheelchair was equipped with two footrests, which resulted in the patient fracturing her right foot. The clinical record for Patient A was reviewed. The document titled "Record of Admission" dated 9/4/10, indicated Patient A was admitted to the facility with diagnoses that included abnormal posture and muscle weakness. The facility document titled "Change of Condition Form" dated 8/31/10, read "Patient (Patient A) has bruise on right little toe. According to the CNA (Certified Nursing Assistant), she was transferring patient (Patient A) in wheelchair to therapy room. Patient had only one footrest; she was resting her feet on that. Her right foot dropped + dragged on the floor + she got a bruise on her right little toe. MD (medical doctor) notified. Ordered X-ray of right foot today." The document titled "Diagnostic Imaging Report" of an X-ray of Patient A's right foot, dated 8/31/10 at 11:27 PM, read "There is a fracture involving the right fifth metatarsal (toe)....Conclusion: Acute right foot fracture (recently broken foot)." The document titled "Minimum Data Set" (MDS-an assessment tool) dated 9/3/10 indicated Patient A had partial loss of voluntary movement of her legs and feet, needed staff to transport her in a wheelchair, and had a diagnosis of osteoporosis (A disease in which the bones become extremely porous and are subject to a fracture). During an interview with Licensed Vocational Nurse (LVN 1) on 9/15/10 at 1:15 PM, she stated she was on duty the day Patient A experienced the fracture. LVN 1 stated she remembered CNA 2 was preparing to take Patient A to therapy and was looking for two footrests to put on the wheel chair but could only find one (the footrests attach to the wheelchair and provide a surface for the feet to rest upon which prevents them from dragging on the ground). LVN 1 stated when CNA 2 could not find a second footrest, she (CNA 2) wheeled Patient A along the hallway with one footrest to rest both her feet. Patient A's right foot fell off the one footrest and was caught in the carpet resulting in a fracture to her foot. Therefore, the facility failed to ensure the wheelchair for Patient A was equipped with two footrests which resulted in her right foot sustaining a fracture. This failure had a direct relationship to the health, safety, or security of patients. |
| 120000328 |
The Rehabilitation Center of Bakersfield |
120010407 |
B |
12-Feb-14 |
88H711 |
1999 |
Health and Safety Code 1418.91(a) (b) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours.(b) A failure to comply with the requirements of this section shall be a class "B" violation.On June 21, 2012 at 3:35 PM, an unannounced visit was made to the facility to investigate an entity reported alleged staff to resident altercation. The incident was reported to the Department of Public Health on 6/4/12, at 4:44 PM.Based on interview and record review, the facility failed to report an allegation of staff to resident altercation to the California Department of Public Health (CDPH) within 24 hours.Resident A was a 72 year old female and she was her own responsible party. She had a diagnosis of difficulty in walking and muscle weakness. Resident 1's Care Plan indicated she required extensive assistance with one to two staff assist for toilet use and transfers and the approach plan included "have call light within reach and answer promptly." The "Nurse's Notes dated 6/3/12, not timed, read " at 6 AM Resident had altercation with the CNA (Certified Nursing Assistant)... put on call light...CNA told me the morning shift will take me to the bathroom and she left...Called a second time and CNA returned ... she was yelling at me..." Nurse's notes dated 6/3/12, at 11:45 AM indicated staff had called the Director of Nurses and made her aware of the incident between Resident 1 and the CNA.During an interview with the Assistant Director of Nursing (ADON) on 6/21/12 at 3:35, she stated Resident A was able to recount the incident that happened at 6 AM on 6/3/12, between her and CNA 1 without problems. This alleged event was reported to Department on 6/4/12 at 4:55 PM.Therefore, the facility failed to notify the Department of an allegation of abuse within 24 hours.In accordance with Health and Safety Code Section 1418.91, this violation is a class B violation. |
| 120001408 |
Tulare Nursing & Rehabilitation Center |
120010479 |
B |
26-Feb-14 |
2HE211 |
1643 |
Health and Safety Code 1418.91(a)(b) (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the Department immediately, or within 24 hours. (b) A failure to comply with the requirements of this section shall be a class "B" violation. On 5/9/13 at 10 AM, an unreported allegation of abuse was discovered during a licensing/recertification survey.Based on interview and record review the facility failed to report an allegation of abuse for one resident (Resident A) within 24 hours.Resident A was a 59-year-old woman with diagnoses including dementia, psychosis, depression, and anxiety. According to the facility report the resident is alert with confusion and requires extensive assistance with most activities of daily living. On 5/9/13 at 10 AM, the facility Administrator showed the surveyor evidence of past allegations of abuse, including an allegation regarding Resident A. The administrator stated the allegation regarding Resident A involved financial abuse by the resident's daughter, Family Member (FM) 1. "We didn't report (to the Department) because (FM 1) was outside the facility." The subsequent facility report to the Department dated 5/13/13, specified the Social Services Director became aware of the allegation on 1/22/13, when FM 1, who received Resident A's funds, failed to meet a deadline on 1/18/13 to pay a seriously delinquent share of cost of $1325. Therefore the facility failed to report an allegation of abuse of a resident within 24 hours. The above violation has a direct relationship to the health, safety or security of residents. |
| 120000328 |
The Rehabilitation Center of Bakersfield |
120010486 |
A |
26-Feb-14 |
M5UD11 |
7447 |
F223, 483.13(B) Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. On 5/14/13, at 11:15 AM, an unannounced visit was made to the facility to investigate an entity reported incident for an alleged sexual assault of a resident (Resident 1) by another resident (Resident 2). Based on interview and record review, the facility failed to: 1. Protect Resident 1 from a sexual assault by Resident 2. 2. Develop a plan of care for Resident 2 who was known to be sexually inappropriate and wander the facility. These failures resulted in Resident 1 being sexually assaulted causing injuries that required medical intervention and loss of dignity. Resident 1 has a history of dementia (Deterioration of intellectual faculties, such as memory, concentration, and judgment), stroke, dysphagia (Difficulty swallowing), and depression (severe despondency and dejection, typically felt over a period of time and accompanied by feelings of hopelessness and inadequacy). Resident 2 has a history of dementia, depression, and sexually inappropriate behavior. During an interview with the Responsible Party (RP), on 5/14/13, at 1:30 PM, he stated, "They (the facility) called me around 4 AM. One of the staff told me that my mom was allegedly sexually abused." During an interview with Licensed Vocational Nurse 1 (LVN 1), on 5/17/13, at 5:10 AM, he stated, "One of the Certified Nursing Assistants (CNA 1) was asked what happened. She stated she was about to clock in. Somebody was moaning so she looked inside the room. (Resident 2) was already on top of (Resident 1), between her legs, pants pulled down. She was not in pain at that time, but I noticed there were some bleeding on the vulvar area (The external genital organs of the female)." During an interview with CNA 1, on 5/17/13, at 5:30 PM, she stated she was on her break and was about to clock in when she heard somebody moaning. She stated, "I went inside the room and saw (Resident 2) sitting on the bed of (Resident 1) with his leg spread on her....her (adult brief) Velcro (a fastener) was taken off. Hand prints with blood were on her two pillows, one on her head and the other one was on her left side under the arm, both of them have blood." During a review of the clinical record for Resident 2, the MDS (Minimum Data Set-an assessment tool) assessment dated 5/2/13, indicated Resident 2's cognitive skills for daily decision making was "moderately impaired", decisions poor: cues/supervision required. The psychiatric note dated 3/29/13, read, "Risperdal (an antipsychotic drug) 0.5 mg (milligrams) BID (two times a day) for delusions m/b (manifested by)inappropriate sexual behavior." The Interdisciplinary team (IDT) Progress notes dated 4/1/13, read, "Started on Risperdal 0.5 mg PO (by mouth) delusion inappropriate sexual behavior-sexual ideation with young girls. Could not distinguish his own age anymore. More confused-wanders without purpose. Unaware of the environment." The IDT progress notes dated 4/17/13, at 2 PM, read "Res (Resident 2) continues to have Risperdal 0.5 mg BID ordered for delusions m/b inappropriate sexual behavior." The physicians telephone orders dated 4/19/13, at 2 pm, read "D/C (discontinue) previous Risperdal order. Start Risperdal 2 mg PO BID DX (diagnosis) delusions m/b inappropriate behavior." The Social Services Assessment (SSA) dated 3/27/13, read "Res (Resident 2) conts (continues) to ambulate throughout the facility but gets easily disoriented and needs to be re-oriented to room. Res (Resident 2) also had inappropriate sexual episodes....Res (Resident 2) has been told to close curtains or door. Res (Resident 2) agreed but after conversation resident could not recall conversation." Social Services notes dated 4/16/13, read "Nursing reports that resident wandered into another person's room to use the bathroom. Res (Resident 2) remains confused ambulated freely."The nurses progress notes dated 5/11/13, read "Resident (Resident 2) is starting to ambulate alone about facility unsupervised. Becomes upset and angry when told he needs to use w/c (wheel chair) when going about facility." The facility document titled "Resident Care Plans" for Resident 2 were reviewed (plan of care are developed to address resident behavior and needs). Resident 2 did not have a care plan in place to address his sexually inappropriate behaviors. During a concurrent interview with the Director of Nursing (DON) and review of Resident 2's clinical record, on 5/14/13, at 2:05 PM, she verified Resident 2 did not have a care plan in place to address his sexually inappropriate behaviors. During a review of the clinical record for Resident 1, the nurses progress notes dated 5/14/13, at 3:10 AM through 6 AM, read "Res (Resident 2) noted by CNAs to be in females room sitting next to her (Resident 1). Noted all clothes on him....Female res (Resident 1) with her diaper pulled down. Res (Resident 2) became anger with staff when told to go to his room. Lic (license) Nurse was able to get him to go to his room. Res (Resident 2) denies doing anything to female resident (Resident 1). Lic Nurse called DON who called 911reported res (Resident 2) for suspected physical abuse to another female resident (Resident 1). Tx (treatment) Nurse-An abrasion was found to inner labia with a small amount of dried blood on her brief. Resident (Resident 1) also has abrasion to lower inner vagina. There was a small amount bright red blood on her brief." Resident 1's MDS assessment dated 4/22/13, indicated she had a short and long term memory problem. The Emergency Aftercare Instructions from the hospital dated 5/14/13, at 7:34 AM, read "Diagnosis Vulva Trauma, alleged Sexual Assault." The facility policy and procedure titled "Care Planning" revised 1/1/12, read "The Facility's Interdisciplinary Team (IDT) will develop a Care Plan for each resident. The Care Plan serves as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address their medical, nursing, mental, and psychosocial needs. A Licensed Nurse will initiate the Care Plan, and the plan will be finalized in accordance with Resident Assessment Instrument (RAI) guidelines and updated as indicated for change in condition, onset of new problems and resolution of current problems. The facility policy and procedure titled "Abuse-Prevention Program" revised 1/1/12, read "Resident Assessments and Care Planning are performed to monitor resident needs and address behaviors that may lead to conflict." The facility policy and procedure titled "Violence Between Residents, Operational Manual-Abuse & Neglect" revised 1/1/12, read "Facility's staff monitors residents for aggressive or inappropriate behavior toward other residents, family members, visitors, or facility staff." Therefore, the facility failed to protect Resident 1 from sexual assault by Resident 2 which resulted in a violation of resident's rights, physical harm, and loss of dignity. The facility failed to ensure a care plan was developed for Resident 2 who exhibited sexually inappropriate behavior, to prevent a sexual assault to Resident 1.These facility's actions caused harm to Resident 1 or a substantial probability that death or serious physical harm could result. |
| 630012057 |
Twin Oaks Rehabilitation & Nursing Center |
120010515 |
B |
06-Mar-14 |
G40C11 |
1915 |
Health and Safety Code 1418.91 (a)(b) 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. On7/16/12, at 11:15 AM, an unannounced visit was made to the facility to investigate an entity reported incident regarding an allegation of resident abuse. Based on interview and record review, the facility failed to notify the California Department of Public Health of an allegation of abuse which occurred on 7/2/14. During an interview with the Administrator on 7/16/12 at 11:15 AM, he stated the facility's investigation verified that Certified Nursing Assistant (CNA) A had used foul language while taking care of Resident 1, but he felt it was directed at the situation and not the resident. The Administrator stated he did not report the allegation of abuse to the Department.During an interview with Resident 1 on 7/16/12 at 11:40 AM, she stated CNA A came into her room to help her to the restroom (7/2/12). She stated when CNA A saw Resident 1 had soiled herself, she started using foul language. Once they were in the restroom, she stated CNA A continued to use foul language while she was cleaning her up. She stated, "I knew she (CNA A) was upset about something, I didn't ask what was wrong. I didn't want her to get more upset. I felt scared."The facility policy and procedure titled Reporting abuse to State Agencies and Other Entities/Individuals" undated, read "Should an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse be reported, the facility administrator or his/her designee, will notify the following persons or agencies: The State licensing/certification agency responsible for survey/licensing the facility." |
| 120001408 |
Tulare Nursing & Rehabilitation Center |
120011078 |
A |
27-Oct-14 |
KJOG11 |
3709 |
483.25(h) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. An announced visit was made to the facility on 9/25/14 to investigate a resident fall with injury. Resident A was an 86 year old female admitted to the facility on 11/5/2009. She had a diagnosis of muscle weakness, psychosis, senile dementia, depression, Alzheimer's disease, and difficulty walking. Based on observation, interview, and record review, the facility failed to ensure Resident A's posterior support straps (used to help resident sit up straight instead of leaning forward.) were on when she was in her wheelchair. This failure resulted in Resident A falling out of her wheelchair and sustaining a fracture (a break in the bone) to her nose.Findings:During an observation on 9/25/14 at 1:15 PM, Resident A was seated in a chair in the beauty salon and a hairdresser was trimming her hair. Resident A was slumped forward in the chair with head bowed and did not respond when the hairdresser spoke to her. The hairdresser lifted Resident A's head by reaching under her chin.During an interview with the Director of Nursing (DON) on 9/25/14 at 1:20 PM, she stated, Resident A has fallen out of the wheelchair in the past and suffered bruises to her face. The DON stated Resident A had falls on 3/2/14, 5/30/14, 6/17/14, and 7/17/14. Resident A had a physician's order for the use of posterior support straps to help her sit up straight and to prevent her from leaning forward. During a subsequent interview with the DON, on 10/16/14, at 12:30 PM, she stated the posterior support straps were to be used to prevent Resident A from falling out of her wheelchair.During an interview with Certified Nursing Assistant (CNA) 1, on 9/25/14 at 2:30 PM, she stated on the day of the fall (9/14/14), "I went in her (Resident A's) room and she was leaning forward. I said, '(Resident A), let's go to bed.' She said something to me and she was leaning too far forward and toppled to the floor. She bled from the middle of her nose" (CNA 1 pointed to the bridge of her nose). CNA 1 also stated that at the time of the fall the posterior support straps were not on Resident A.During a review of the clinical record for Resident A, the Physician's Order sheet, dated 5/6/13, indicated Resident A was to have postural shoulder support on when she was up in her wheelchair. Physical Therapy Discharge Summary notes, dated 2/18/13, indicated Resident A was to use the postural shoulder straps to prevent her from leaning forward. A clinical assessment report dated 9/15/14 by the IDT (Interdisciplinary Team) indicated: on 9/14/14, "At approximately 2145 (9:45 PM), CNA was pushing elder into her room to change her when elder leaned forward and out of her chair causing her to fall onto floor. No restraints in use. Resident frequently leans forward while (in) wheelchair and on this occasion fell forward out of chair. Skin tear noted to bridge of nose, cleaned and applied steri-strip (tape used to close a wound). Bruising and swelling noted to elders right eye and nose." An X-ray report dated 9/15/14 indicated Resident A suffered a minimally depressed fracture (bone is pushed in) of the distal aspect of the nasal bones (lower end of the nose).The facility policy titled "Fall Prevention Program", revised 9/19/12, indicated all elders were to receive adequate supervision and assistive devices to prevent accidents.The above violation presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 120000328 |
The Rehabilitation Center of Bakersfield |
120011715 |
B |
15-Sep-15 |
DMR411 |
3276 |
Health and Safety Code 1418.91(a):(a) A long-term health care facility shall report all allegations of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. (b)A failure to comply with the requirements of this section shall be a class "B" violation. On 8/24/15, at 1:13 PM, an unannounced visit was made to the facility to investigate a complaint regarding alleged abuse between staff members and a resident. Based on interview and record review, the facility failed to report an allegation of abuse for one of one sampled resident (1) to the Department of Public Health, when Resident 1 reported verbal and physical abuse to the facility. This had the potential for abuse allegations for other incidents of alleged abuse to go unreported and uninvestigated by the Department. During an interview with Resident 1, on 8/24/15, at 11:04 AM, she stated, "A young male CNA [Certified Nursing Assistant] was very cruel, he took me in my room, shut the door and was laughing at me." When asked what happened, she stated, "I fell to the floor and a female Hispanic staff said to me, 'How do you like to be on the floor, you are a nurse let's see how you can get yourself up. Look, you can't get up. They think it was funny. Two to three staff laughed at me." When asked if she reported the incident, she stated, "Yes, I reported to the LVN [Licensed Vocational Nurse]. I also told the DON [Director of Nursing. During an interview with the DON, on 8/24/15, at 2:59 PM, when asked if she received a report from Resident 1 about abuse allegations, she stated, "Yes. It [abuse allegations] was not reported to the State because resident [1] was confused. It wasn't reported because it wasn't making any sense." When asked if DON was aware of reporting allegations of abuse, she stated, "I know how to report." DON stated, "I did not think abuse happened, I asked the staff right away but resident's [1] story was inconsistent considering her [Resident 1] history of behaviors." During an interview with the Administrator [Abuse Coordinator], on 8/27/15, at 11:39 AM, when asked if he received any report of allegation of abuse from Resident 1, he stated, "No. Nobody reported to me." When asked what was their policy on reporting abuse with regards to allegations of abuse from confused residents, he stated, "Confused or not confused, any allegations of abuse should be reported and investigated." The facility policy and procedure titled, "Reporting Abuse", dated 1/7/11, indicated, "Abuse of an elder or dependent adult means physical abuse, neglect, financial abuse, abandonment, isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering, or the deprivation by care custodian of goods and services that are necessary to avoid physical harm or mental suffering. Verbal abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability." The facility policy and procedure titled, "Abuse-Prevention Program", dated 1/1/12, read, "The facility will report incidents of abuse promptly to appropriate agencies." |
| 120000328 |
The Rehabilitation Center of Bakersfield |
120011906 |
B |
17-Dec-15 |
E1PW11 |
12901 |
F 325 Based on a resident's comprehensive assessment, the facility must ensure that a resident(1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem. On 10/26/15, at 8:30 AM, an unannounced recertification survey visit was made.Based on observation, interview, and record review, the facility failed to:1) Appropriately address/respond to one of 24 sampled resident's (1) significant weight loss in a timely manner. This resulted in the resident losing additional weight which had the potential for a decline in the health and wellness of the resident.2) Accurately record the meal intake percentage for one (11) of 24 sampled resident's two observed meals, a resident with identified significant weight loss. This had the actual result of inaccurate assessment data.3) Conduct weights as per facility policy for one (11) of 24 sampled residents for her first month in the facility. This had the potential for delayed identification of a significant weight loss.1. Resident 1 is a 61 year old male who was originally admitted on 2/20/15 and readmitted on 10/9/15 with diagnoses of peripheral vascular disease, muscle weakness, complete traumatic amputation (surgical removal) at the knee level of left lower leg, partial traumatic amputation of the right foot at the ankle level, and partial traumatic amputation of two or more lesser toes to the right foot. He is receiving treatment to the left foot and has a wound vacuum (a vacuum source creates continuous or intermittent negative pressure inside the wound to remove fluid and infectious material to promote healing). In addition, he is also diagnosed with Diabetes Mellitus Type II (a chronic condition that affects the way your body metabolizes sugar), and neuropathy (damage to the peripheral nerves typically causing numbness or weakness). The Minimum Data Set (MDS assessment) indicates the resident is cognitively intact and requires extensive assistance with transferring and is not ambulatory. During an initial tour observation with the Director of Staff Development (DSD), on 10/26/15, at 9:30 AM, Resident 1 was observed lying in bed. When the clothes closet was opened there were several opened and unopened food items noted including bags of potato chips, cheese puffs, cereal (fruit loops), and drinks. During an observation on 10/26/15, at 11:38 AM, Resident 1 was observed lying in bed with the head of the bed up and a friend at his bedside. Resident 1 was eating a burrito and drinking a Starbuck's coffee. Resident 1 stated his friend purchased the burrito for him because he did not like "anything coming out of the [facility] kitchen". Resident 1 acknowledged he turned the facility lunch tray away.During an observation and concurrent interview on 10/27/15, at 8:40 AM, Resident 1 was observed eating a bowl of fruit loops. He acknowledged the fruit loops were from his personal inventory and they were a bit stale since he purchased them prior to his most recent discharge from the hospital (sometime in 9/15). He stated, he did not like the food provided by the facility; therefore, chose to eat his own food items.During a subsequent interview with Resident 1, on 10/27/15, at 1:02 PM, he stated, "I can't stand the food." Resident 1 stated, "I've told everyone." During a review of the clinical record for Resident 1, the physician's orders were reviewed. The resident was readmitted on 10/9/15 from the acute hospital. The resident was receiving a no added salt, no concentrated sweets diet. The documented weight trend was as follows: 10/10/15 - 224.0 pounds (lbs) 10/17/15 - 207.5 lbs (weight loss of 16.5 lbs in one week, 7.3 % weight loss in one week) 10/19/15 - 204.0 lbs (weight loss of 3.5 lbs in two days) 10/24/15 - 182.0 lbs (weight loss of 25.5 lbs in one week, 12.2 % weight loss in one week). During a concurrent interview and record review with the Licensed Nurse (LN 1), on 10/29/15, at 1:50 PM, she was asked if significant weight changes were reported to the physician. She acknowledged, the physician should be notified of significant weight changes.She was asked if the weight loss of 16.5 lbs in one week that occurred between 10/10/15 and 10/17/15, with Resident 1, was reported to the physician timely to be acted upon. She stated, "If the physician was notified, a change of condition report would be placed in the resident's clinical record and the nurse would document the physician notification in the nurse's notes." After reviewing Resident 1's clinical record, she was unable to find documented evidence the physician was notified timely of the significant weight change that occurred between 10/10/15 and 10/17/15. The change of condition report and the evidence the physician was made aware of the change in weight, was documented in Resident 1's clinical record on 10/28/15 (11 days later), when the resident lost an additional 25.5 lbs, for a total weight loss of 42 lbs in a two week span. LN 1 stated, "It was the restorative nursing assistants (RNAs) who were responsible for weighing the residents and notifying the nursing staff of the weight changes.)During a concurrent interview and record review with RNA 1, on 10/29/15, at 2 PM, she stated the restorative department weighs the residents on Saturday and Sunday, and LN 4 reviews those weights on the following Monday.During an interview with LN 4, on 10/29/15, at 2:05 PM, she was asked the process when a significant weight change occurs with a resident. She stated, the licensed nurses should create a change of condition report and notify the physician and both the change of condition report and the notification to the physician should be documented in the nurse's notes. After reviewing Resident 1's clinical record, she was unable to find evidence a change of condition document was created or that the resident's physician was notified of the significant weight loss of 16.5 lbs in one week, which occurred with Resident 1 between 10/10/15 and 10/17/15. It was not until 10/28/15, when a change of condition report was noted and the physician was made aware of a significant weight change. She stated, "The interdisciplinary team (IDT) should have met the following week with recommendations. "During a review of the 10/21/15 IDT note, it was noted the IDT recommended a sugar free house nourishment three times a day during medication pass. After a subsequent interview with LN 4, she stated the resident was already receiving a house nourishment and could not state the reason the IDT recommended something the resident was already receiving.During a concurrent interview and clinical record review, with the Dietary Services Supervisor (DSS), on 10/29/15, at 2:40 PM, the document titled, "DIET HISTORY/FOOD PREFERENCES", dated 10/12/15, was reviewed. Under the dislikes section, "Eggs" were marked as the only disliked item. The DSS, was informed, the resident stated he did not like any of the food served in the facility. She acknowledged, she was aware of this and stated prior to his latest discharge, the facility staff would purchase the resident outside food because he was "picky". She acknowledged the "DIET HISTORY/FOOD PREFERENCES", should have been updated with his dislikes.The facility policy and procedure titled, "Evaluation of Weight & Nutritional Status", date revised 8/1/14, defines significant weight loss as 5% in one (1) month, 7.5% in three (3) months, or 10% in six (6) months..." It further indicates, III...Clinical Evaluation...B. Any resident weight that varies from the reporting period by 5% in 30 days, 7.5% in 90 days, 10% in 180 days, will be evaluated by the IDT [Interdisciplinary Team]...i. Once weight gain or loss...is identified, the IDT...Committee will...Notify the Attending Physician..."The facility policy and procedure titled, "RDs FOR HEALTHCARE, INC. WEIGHT CHANGE PROTOCOL", undated, indicated, "Early identification of a weight problem and possible cause(s) can minimize complications...Residents will be weighed on a monthly basis and weekly for those newly admitted and those deemed to be at high risk for weight changes...The following criteria define significant or insidious weight changes...3# (pounds) weight loss or gain in 1 week or as facility policy states...5# weight loss or gain in 1 month...5% weight loss or gain in 1 month..7.5% weight loss or gain in 3 months..." Under the "ASSESSMENT" subheading it indicates, "Determine if the...weight change is felt to be temporary or permanent...weight change is an expected or desired outcome...diet order is appropriate to meet the goal...meals sent to resident meet their needs and goals...intake of the resident will be sufficient to meet needs or goals..." 2. Resident 11 is an 87 year old female, who was admitted on 8/15/15 with diagnoses of hypotension (low blood pressure), diverticulosis (a condition in which the diverticula [an abnormal sac or pouch formed on the intestinal wall] are present in the intestine without inflammation), gastrointestinal (of or related to the stomach or intestines) hemorrhage (a profuse discharge of blood), and muscle weakness.During a review of the clinical record for Resident 11, the document titled "Vital Signs and Weight Record" indicated Resident 11 weighed 191.6 pounds on 9/6/15, but weighed 179.4 pounds on 10/5/15, showing a loss of 12.2 pounds in one month. This calculates to over a 6% weight loss in one month. The document titled MDS (Minimum Data Set, a comprehensive standardized assessment tool), dated 10/10/15 indicated the 179 pound weight was significant, since it was over a 5% loss in one month. The MDS also indicated this was a weight loss not prescribed by her physician. The document titled "IDT Assessment of Significant Weight Change / Hydration / Skin status", dated 10/16/15, read "Weight loss may be due to decreased PO [by mouth] intake..."The document titled "Nutritional Progress Notes", dated 10/21/15, and written by a Registered Dietician, indicated Resident 11 lost additional weight, now calculated to be a 15.6 pound weight loss, or a 8.1% loss over one month.The document titled "Nutritional Status - Interdisciplinary Care Plan" dated 10/21/15, indicated under "Goal", for Resident 11 to "consume 75-100% of meals." The Care Plan indicated under "Approach / Interventions" to "Monitor for acceptance & tolerance of diet", "Monitor meal intake", and "Encourage to eat 75% of meals." The document containing the meal percentages for October 2015 was reviewed, and contained many illegible entries, making it impossible to determine how much food Resident 11 consumed for many meals.During an observation on 10/26/15 and 10/27/15, of Resident 11's lunches those days, she was noted to eat only a bite or two of each meal.During a concurrent record review and interview with the Dietary Services Supervisor (DSS) on 10/29/15, at 2:45 PM, she was asked what was the meal percentage consumed by Resident 11 for her noon time meal on 10/26/15, and on 10/27/15, according to the documentation. The DSS looked at the documentation, and stated "It's hard to tell" and stated "70%" for the lunch on 10/26/15, and "70%" for the lunch on 10/27/15.During a concurrent record review and interview with the Medical Records Director (MRD) on 10/29/15, at 10:45 AM, she was asked the same questions, and MRD 1 answered "60%" for 10/26/15, and "100%" for 10/27/15.During a concurrent record review and interview with Licensed Nurse 7 (LN 7), on 10/29/15, at 12:35 PM, she was asked the same questions, and LN 7 answered "75%" for 10/26/15, and "65%" for 10/27/15.3) The facility policy and procedure titled "Evaluation of Weight & Nutritional Status," dated 8/1/14, read "Each resident will be weighed within twenty-four (24) hours of admission, weighed weekly for four (4) weeks, and weighed monthly or as needed thereafter. The weight will be documented in the resident chart and accompanying forms."During a review of the clinical record for Resident 11, the document titled "Face Sheet" indicated she was admitted to the facility on 8/15/15.During a review of the clinical record for Resident 11, the document titled "Vital Signs and Weight Record" indicated Resident 11 weights were as follows: 8/15/15 = 196.4 pounds (admission weight) 9/6/15 = 191.6 pounds 10/5/15 = 179.4 poundsThe weights, which according to the facility's policy and procedure, that were to have been done on 8/22/15 and 8/29/15, could not be found in the clinical record.During a concurrent record review and interview with the Registered Dietician, on 10/28/15, at 8:40 AM, she indicated the new admission weekly weights had not been conducted for Resident 11.The above violations have a direct or immediate relationship to the health and safety of the residents. |
| 120000328 |
The Rehabilitation Center of Bakersfield |
120011908 |
B |
18-Dec-15 |
E1PW11 |
6533 |
F 241-42CFR 483.15(a) Dignity and Respect of IndividualityThe facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. On 10/26/15, at 8:30 AM, an unannounced recertification survey visit was made. Based on observation, interview, and record review, the facility failed to: Treat one of 24 sampled residents (21), one of seven random residents (27) and one of seven confidential residents (30) with respect and dignity. This resulted in residents having low self-esteem and embarrassment.Findings: 1. Resident 21 is a 79 year old female who was originally admitted to the facility on 8/29/15 with a diagnosis of C-spine fracture (broken neck), history of seizures, hypertension, and right frontal stroke. She was described in the medical record as being unable to walk independently and was wheel chair bound. The medical record stated that she was forgetful and at times and was unable to communicate her needs. During a concurrent interview with Resident 21 and Family 2, on 10/26/15, at 9 AM, Resident 21 stated she remembered going to a doctor's appointment with no shoes on. Family 2 stated the staff gave a reason for that particular incident but there have been several incidents regarding dressing and preparing her for activities in a dignified manner. Family 2 stated she feels like staff treats her like that because "Oh it's just her... as if she won't remember." During an interview with License Nursed (LN) 3, on 10/29/15, at 10:50 AM, she stated she knew about the incident when she was sent to Physical Therapy wearing just a gown and other times when she was not dressed appropriately for therapy and doctor's appointments. During an interview with Certified Nursing Assistant 1 (CNA 1), on 10/29/15, at 11 AM, she stated, "I was here when she went to the doctors with no shoes. Night shift dressed her so I did not check her before leaving... She also needs to have a prosthetic bra (a contoured device which simulates breast tissue, usually worn inside a brassiere which is composed of foam or gel) and a neck collar (type of brace worn around the neck for support or stabilization). I told my supervisor and she told the night shift staff... I don't know why it's still happening." During an interview with LN 1, on 10/29/15, at 2 PM, she stated, "I heard the complaints to my staff regarding different incidents of not putting Resident 21's neck brace back after showers, not having shoes at doctor's appointments and wearing night gowns to Physical Therapy." During a review of the clinical record for Resident 21, the "Care Plan Activities of Daily Living (ADL) Functional", dated 9/13, indicated Resident 21 needs "extensive assist with dressing" and that Resident 21 "would be dressed appropriately."The facility policy and procedures titled "Residents Rights- Quality of Life" revision date 1/12 indicated under Procedure "...X. Facility Staff promotes, maintains, and protects resident privacy, including bodily privacy, when assisting with personal care during treatment procedures. XI. Demeaning practices and standards of care that compromise dignity are prohibited. Facility Staff will promote dignity and assists residents as needed..." 2. Resident 27 is a 78 year old female who was originally admitted to the facility on 4/02/14, with diagnosis of convulsions, anemia, malaise, and arthropathy (disease of the joint). She was described in the medical record as being alert and oriented and able to communicate her needs. She is unable to walk independently and requires a wheel chair to move from one place to the other. During an interview with Resident 27, on 10/28/15, at 10:28 AM, she stated, "I call the staff when I need water or to use the bathroom. I would do it myself but I can't get out of bed on my own. I have had to pee in bed about ten times in the last few weeks because they (staff) took so long to come help me. I felt so sad, like a baby wetting her clothes, humiliating it's horrible. The staff tells me that they couldn't help me because they are working short staffed."During a review of the "Grievance/Complaint log" with Social Service Director (SSD) on 10/29/15, at 10:54 AM, she was asked about the multiple grievances and complaints of "CNAs' turning call lights off without completing the task." She stated, "The CNA's are talked to." 3. Resident 30 is a 68 year old female who was originally admitted on 11/08/13 and readmitted on 9/29/15 with diagnosis of myocardial infarction (heart attack), chronic heart disease, heart failure, cerebrovascular disease, hypotension, Neuralgia, urinary tract infection, difficulty in walking, and history of falls. She was described in the medical record as being alert and oriented and able to communicate her needs. She is unable to walk independently and requires a wheel chair to move from one place to the other. During an interview with Resident 30, on 10/28/15, at 10:30 AM, Resident 30 stated it does take on average 30 to 45 minutes for her needs to be taken care of. She stated she calls for such things as water and assistance to the bathroom and assistance with cleaning herself up after she has used the bathroom. She stated, without the staff assistance she cannot get to the bathroom on time. When the staff have taken too long to answer the call light, she stated she has had accidents (incontinent [lack of urinary control] episodes). She stated, "It makes me feel bad...you're grown and someone has to change you."The facility policy and procedure titled, "Call System", dated 6/15/11, read in part, "To provide a mechanism for residents to promptly communicate with staff....The Facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities...Nursing staff will answer call bells promptly...Upon responding to request, if item is requested that is not available...assistance will be obtained from the Charge Nurse...In answering to request, staff will return to resident with the item or reply promptly...Assistance will be offered before leaving...Call bells located within resident bathrooms are considered "emergency calls" due to the potential for falls and injury...These lights have a more frequent audio sound and the call light above the room door may be red. The above violations have a direct relationship to cause significant humiliation, indignity, anxiety, or other emotional trauma to the residents. |
| 120000328 |
The Rehabilitation Center of Bakersfield |
120012085 |
B |
16-Mar-16 |
DFUG11 |
4644 |
T22 72520(a)(b)(c) (a) If a patient of a skilled nursing facility is transferred to a general acute care hospital as defined in Section 1250(a) of the Health and Safety Code, the skilled nursing facility shall afford the patient a bed hold of seven (7) days, which may be exercised by the patient or the patient's representative. (b) Upon admission of the patient to the skilled nursing facility and upon transfer of the patient of a skilled nursing facility to a general acute care hospital, the skilled nursing facility shall inform the patient, or the patient's representative, in writing of the right to exercise this bed hold provision. No later than June 1, 1985, every skilled nursing facility shall inform each current patient or patient's representative in writing of the right to exercise the bed hold provision. Each notice shall include information that a non-Medi-Cal eligible patient will be liable for the cost of the bed hold days, and the insurance may or may not cover such costs. (c) A licensee who fails to meet these requirements shall offer to the patient the next available bed appropriate for the patient's needs. This requirement shall be in addition to any other remedies provided by law. Based on interview and record review, the facility failed, upon transfer to the acute hospital, to offer a seven day bed hold, offer the first available bed, and readmit one of one sampled patient (1). This resulted in a violation of Patient 1's admission agreement and Regulation. The clinical record for Patient 1 was reviewed. The nurses notes" dated 2/18/16, indicated Patient 1 was admitted the acute hospital." During an interview with Admission Coordinator (AC) 1, on 2/26/16, at 2:42 PM, she stated when the patient was admitted (1/4/16) to this facility the patient had 30 Medicare days. After exhausting the 30 Medicare days the patient's primary insurance became Healthnet. AD 1 stated Healthnet insurance did not pay the facility for the patient's stay from 2/3/16-2/18/16. The facility could not readmit the resident yet until the facility get an authorization from Healthnet insurance. During an interview with AC 2, on 2/26/16, at 2:59 PM, she stated they (Admission staff) told the son to dis-enroll the patient with Heathnet and just do a straight Medi-cal insurance. However, when the facility checked the patient's insurance the patient still had Healthnet insurance. The facility would check the patient's insurance again on Tuesday (3/1/16). AC 1 stated the facility would not re-admit the patient yet. During an interview with the Director of Nursing and the Administrator on 2/26/16, at 3:59 PM, the Administrator and DON were made aware of the facility's responsibility of readmitting the patient back to the facility because the patient was medically stable and ready to come back. Administrator stated he would not accept the patient for free. He also stated, "I'm willing to accept the deficiency." During an interview with Family Member (FM) 1, on 3/3/16, at 11:45 AM, he stated the patient was still in the hospital and the facility still did not readmit the patient back. The admission agreement dated 1/4/16, and signed by Resident 1's responsible party (FM 1), read "If you must be transferred to an acute hospital for seven days or less, we will notify you or your representative that we are willing to hold your bed. You or your representative have 24 hours after receiving this notice to let us know whether you want us to hold your bed for you. If Medi-Cal [Medicaid] is paying for your care, then Medi-Cal will pay for up to seven days for us to hold the bed for you. If you are not eligible for Medi-Cal and the daily rate is not covered by your insurance, then you are responsible for paying $274/260 for each day we hold the bed for you. You should be aware that Medicare does not cover costs related to holding a bed for you in these situations. If we do not follow the notification procedure described above, we are required by law (Title 22 California Code of Regulations Sections 72520(c) and 73504(c) to offer you the next available appropriate bed in our Facility. You should also note that, if our Facility participates in Medi-Cal and you are eligible for Medi-Cal, if you are away from our Facility for more than seven days due to hospitalization or other medical treatment, we will readmit you to the first available bed in a semi-private room if you need the care provided by our Facility and wish to be readmitted. " The above violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Patient 1. |
| 120001408 |
Tulare Nursing & Rehabilitation Center |
120012380 |
A |
18-Jul-16 |
RM2E11 |
10976 |
F325 Based on a resident's comprehensive assessment, the facility must ensure that a resident - (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem. Based on observation, interview, and record review, the facility failed to take action to prevent weight loss for one of two sampled residents (1) when Resident 1 refused to eat for fourteen days resulting in Resident 1 losing 12 pounds within 14 days. An unannounced visit was made to the facility on 4/22/16 at 9:15 AM, to investigate an allegation of Quality of Care concerning a Resident's unintended weight loss. Resident 1's was a 91 year old female with the diagnoses of Type 2 Diabetes (abnormal sugar levels in the blood), hypokalemia (low potassium levels in the blood), Alzheimer's dementia (a gradual and progressive decline in mental processing ability that affects short-term memory, communication, language, judgment, reasoning, and abstract thinking), and anemia (low red blood cells). The clinical record for Resident 1 was reviewed. The Activities of Daily Living (ADL) care plan for Resident 1 dated 11/24/15, documented an intervention initiated 12/14/15 which indicated Resident 1 required extensive help with one person while eating. The Nutrition log for Resident 1 indicated she refused all meals from 3/29/16 through 4/12/16. The Weights and Vitals Summary for Resident 1 indicated Resident 1 had lost 12 pounds between 3/29/16 and 4/12/16, an average of .86 of a pound a day for 14 days. During a record review on 5/5/16 at 11 AM, the Weight Variance meeting dated 4/7/16 indicated the Registered Dietician (RD) had acknowledged Resident 1's meal intake was low. The RD recommended liberalizing RCS (reduced concentrated sweets) portion and fortifying (adding calories) the diet. The RD indicated Resident 1 had chewing and swallowing problems and was not receiving Speech Therapy. No recommendations were made on how to increase Resident 1's intake of food or evaluating Resident 1's swallowing difficulties. Resident 1's hospital emergency room report dated 4/12/16 indicated: "This 91-year-old female from the nursing home, dementia, full code per the chart, found according to nursing home staff unresponsive and hypotensive (low blood pressure)...Impression: Altered level of consciousness, hypotensive, severe hypernatremia (high amount of salt in the blood usually indicating dehydration), severe electrolyte abnormalities (electrolytes include potassium, chloride and bicarbonate in the blood), renal failure (kidneys that are not filtering the blood) which is acute, and severe dehydration." This report indicated Resident 1's laboratory results were "appreciably worse than a month ago when all those numbers were almost normal". During an interview on 4/22/16 at 10 AM, the Administrator stated the facility had no policy for nutritional interventions for residents. During an interview on 4/22/16 at 10:15 AM, Certified Nursing Assistant (CNA) 1 stated: "She (Resident 1) had a male CNA that she liked that would feed her. He went on nights and she doesn't like to eat for anyone else." During an observation on 4/22/16 at 10:20 AM, Resident 1 was observed in the dining room seated in a wheelchair at a table. During continued observation of the dining room at 11:55 AM, the lunch trays were served and a visitor sat with Resident 1 and attempted to feed her. Resident 1 would jerk her head back when a spoon or cup touched her lips. After 30 minutes of attempted feeding, the meal was discontinued. Resident 1 had eaten approximately 2 teaspoons of food. During a concurrent interview and record review on 4/29/16 at 10:55 AM, Resident 1's medical record was reviewed with the Director of Nursing (DON). The DON could not find notes from the RD and stated the Dietary Services Supervisor (DSS) would make the recommendations and attend the Interdisciplinary (IDT) Meetings. The DON indicated Resident 1 was last seen by a speech therapist for a swallowing evaluation in 2013. The DON verified in the clinical record for Resident 1 there was no documentation of interventions to address Resident 1's refusal to eat beyond the above RD recommendations. During an interview with Licensed Vocational Nurse (LVN) 1 on 4/29/16 at 11:05 AM, she stated if a resident refuses meals, she brings it to the Dietary Supervisor's (DSS) attention. LVN 1 stated that with 20 residents to care for, it was "hard to catch" the resident's refusals. During an interview with the DSS on 5/5/16 at 8:45 AM, the DSS stated when residents refused to eat she "refers to the Registered Dietician immediately" and acknowledged it was unacceptable for a resident to go seven days without food. During an interview with LVN 2 on 5/5/16 at 9:05 AM, she stated she was aware that Resident 1 had stopped eating and stated any nurse that noticed she had stopped eating should have initiated alert charting. LVN 2 stated nurses monitor for 72 hours and then notify the physician and family. During an interview with the RD on 5/5/16 at 9:30 AM, she stated the facility should alert her when a resident stops eating. The RD stated Resident 1 should be receiving 1300-1550 calories daily. The RD stated the supplements were not meal replacements and the Nutritional shakes contain 200 calories per 4 ounces (120 ml) and the medication administration fluid contains 102 calories per 60 ml. F327 The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (1) received sufficient fluid intake to prevent dehydration which resulted in Resident 1 being admitted to the hospital with severe dehydration. An unannounced visit was made to the facility on 4/22/16 at 9:15 AM, to investigate an allegation of Quality of Care concerning a Resident's admission to the hospital with dehydration. Resident 1's was a 91 year old female with diagnoses of Type 2 Diabetes (abnormal sugar levels in the blood), hypokalemia (low potassium levels in the blood), Alzheimer's dementia (a gradual and progressive decline in mental processing ability that affects short-term memory, communication, language, judgment, reasoning, and abstract thinking), and anemia (low red blood cells). The clinical record for Resident 1 was reviewed. The nutrition risk assessment for Resident 1 dated 5/26/16, indicated Resident 1 weighed 131 pounds (59.5 kg) , using the formula of 30 millimeters of fluid intake per kilogram of weight (30 ml/kg) per day, Resident 1 should have been receiving approximately 1800 ml of fluid a day. According to this standard formula, Resident 1 should have been consuming 1581 ml of fluid a day for her weight at this time of 116 pounds (52.7 kg). From the dates of 4/1/16 through 4/12/16, Resident 1 should have consumed 18,972 ml of fluid. Resident 1's actual intake was 7,900 which was a deficit of 11,072 ml or 11.1 liters of fluid. The nutrition log for Resident 1 indicated the following: 4/1/16-fluid intake 620 ml (milliliters) 4/2/16-fluid intake 240 ml 4/3/16-fluid intake 240 ml 4/4/16-fluid intake 960 ml 4/5/16-fluid intake 1320 ml 4/6/16-fluid intake 1080 ml 4/7/16-fluid intake 840 ml 4/8/16-fluid intake 1020 ml 4/9/16-fluid intake 860 ml 4/10/16-fluid intake 480 ml 4/11/16-fluid intake 240 ml 4/12/16- no fluids, transferred to hospital The Activities of Daily Living (ADL) care plan for Resident 1 dated 11/24/15, documented an intervention initiated 12/14/15 which indicated Resident 1 required extensive help with one person while eating. During a record review on 4/22/16 at 12:30 PM, Resident 1's hospital emergency room report dated 4/12/16 indicated: "This 91-year-old female from the nursing home, dementia, full code per the chart, found according to nursing home staff unresponsive and hypotensive (low blood pressure) ...Sodium (a blood test which indicated dehydration) 170 (normal 135-145) ... Osmolality (a blood test which indicated dehydration) is 374 (normal 275-295), very dehydrated...." During an interview on 4/22/16 at 10 AM, the Administrator stated the facility had no policy on preventing dehydration in residents. During an observation on 4/22/16 at 10:20 AM, Resident 1 was observed in the dining room seated in a wheelchair at a table. No cup of fluid was present on her table or other tables. During continued observation of the dining room at a clear plastic glass containing approximately four ounces of water was placed on the table in front of Resident 1. For the next 55 minutes, Resident 1 sat at the table and did not reach for the glass. Resident 1 put her hand in her mouth and made grunting noises. Several staff members passed out beverages to other residents seated at 10 tables with four residents at each table. No staff cued Resident 1 to drink nor assisted in bringing the cup to her mouth. At 11:55 AM, the lunch trays were served and a visitor sat with Resident 1 and attempted to feed her. Resident 1 would jerk her head back when a spoon or cup touched her lips. After 30 minutes of attempted feeding, the meal was discontinued. Resident 1 had drank approximately 20 ml of apple juice. During a concurrent interview and record review on 4/29/16 at 10:55 AM, Resident 1's medical record was reviewed with the Director of Nursing (DON). The DON verified there was no documentation of interventions present in Resident 1's clinical record from 4/1/16 through 4/12/16 which addressed Resident 1's low fluid intake. During an interview with Licensed Vocational Nurse (LVN) 1 on 4/29/16 at 11:05 AM, she stated if a resident refuses meals, she brings it to the Dietary Supervisor's (DSS) attention. LVN 1 stated that with 20 residents to care for, it was "hard to catch" the resident's refusals. During an interview with the DSS on 5/5/16 at 8:45 AM, the DSS stated she looks at the resident's hydration but not daily and only if there is weight loss, wounds or after 14 days of low fluid intake. During an interview with LVN 2 on 5/5/16 at 9:05 AM, she stated she was aware that Resident 1 had stopped eating and stated any nurse that noticed she had stopped eating should have initiated alert charting. LVN 2 stated nurses monitor for 72 hours and then notify the physician and family. During an interview with the RD on 5/5/16 at 9:30 AM, she stated the facility should alert her when a resident decreases their drinking of fluid. The RD stated Resident 1 should be receiving 30 ml/kg of fluid daily and 1300-1550 calories daily. (Resident 1's weight was 116 pounds or 52.7 kilograms; therefore fluid requirement was 1582 ml daily.) 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. |
| 120000328 |
The Rehabilitation Center of Bakersfield |
120012754 |
B |
22-Nov-16 |
LZTA11 |
6461 |
F201 The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; The safety of individuals in the facility is endangered; The health of individuals in the facility would otherwise be endangered; The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; or The facility ceases to operate. Based on interview and record review, the facility inappropriately discharged one of two sampled residents (Resident 1) which resulted in Resident 1 being unsafely discharged home which had the potential to adversely affect Resident 1's health. An unannounced visit was made to the facility on 9/28/16, at 11:27 AM, to investigate an allegation of an inappropriate discharge of a resident. Resident 1 was a 78 year old female with diagnoses that included arthritis (painful inflammation and stiffness of the joints), obesity (excess body fat has accumulated to the extent that it may have a negative effect on health), chronic obstructive pulmonary disease (a type of obstructive lung disease characterized by long-term poor airflow), congestive heart failure (occurs when the heart is unable to pump sufficiently to maintain blood flow to meet the body's needs), deep venous thrombosis (the formation of a blood clot within a deep vein, most commonly the legs), edema to lower extremities (abnormal accumulation of fluid located beneath the skin, which can cause severe pain), high blood pressure, generalized weakness, and chronic lower extremity pain. The clinical record for Resident 1 was reviewed. Patient 1's admission records indicated Resident 1 had both Medicare and Medi-Cal (Medicaid) as insurance providers. The Minimum Data Set (MDS- a comprehensive assessment tool) for Resident 1 dated 9/10/16, indicated under Brief Interview for Mental Status (BIMS) a score of 14 (a score of 13-15 indicates the resident is cognitively intact). The occupational therapy treatment encounter notes for Resident 1 dated 9/23/16, indicated Resident 1 was unable to stand, needed total assistance with dressing her lower body, and maximum assistance for toileting. The nurse's notes dated 9/25/16, at 8 AM, indicated Resident 1 told the staff her family did not want to take her home because they were afraid she would fall. The nurse's notes dated 9/27/16, at 10:30 AM, indicated Resident 1 was discharged home and was transported to her home by a transport van. During an interview with Business Office Assistant (BOA) on 9/28/16, at 11:46 AM, she stated Resident 1 was admitted on 9/3/16, and the last Medicare covered day was 9/23/16. Resident 1 was discharged on 9/27/16. BOA stated Resident 1 owed the facility a total amount of $780.00. BOA stated they (Administrator/BOA) informed Resident 1 she owed the facility the amount of $ 260.00 per day. BOA was asked if they (Administrator/BOA) told Resident 1 she needed to go home because she owed the facility money. BOA stated "(Administrator's name) did." BOA stated on the day of discharge (9/27/16), the facility found out Resident 1 had Medi-Cal insurance. BOA stated she did not tell Resident 1 that she (Resident 1) did not owe the facility money anymore, since the resident had Medi-Cal insurance and the facility could bill the Medi-Cal insurance for the money owed plus pay for her continued stay. During an interview with Occupational Therapy (OT), on 9/28/16, at 12:10 AM, she stated Resident 1 still needed the PT/OT (Physical/Occupational) therapy; however, the facility case manager informed the rehabilitation department not to continue the therapy for Resident 1 because there was no insurance coverage anymore. OT stated Resident 1 needed total assistance with transfers (such as help in and out of her wheel chair, on and off the toilet). OT stated she told Resident 1 if she (Resident 1) were to go home, she would need a Hoyer lift (device used to transfer patients) for transfers. During an interview with Friend 1 (F1), on 9/29/16, at 9:35 AM, she stated when the facility discharged Resident 1 and Resident 1 arrived at the apartment complex on 9/27/16, Resident 1 could not transfer to a wheelchair or walk. F1 stated Resident 1 was yelling because she could not transfer from the car to the wheelchair and Resident 1 was having pain to her lower extremities. F1 stated since Resident 1 was having pain to her lower extremities and could not transfer from the car to the wheelchair, F1 called an ambulance and sent Resident 1 to the local acute hospital. F1 stated "They (facility) kicked her (Resident 1) out" because Resident 1 owed the facility money. During an interview with Resident 1, on 10/11/16, at 2:50 PM, Resident 1 stated she could not remember the date the Administrator went into her room and informed her the insurance had ran out, she owed the facility money, and she needed to go home. Resident 1 stated she did not tell the facility she wanted to go home, they (staff) told her she needed to go home. The clinical record for Resident 1 was reviewed. The emergency department physician notes dated 9/27/16, indicated under History of Present Illness "...complaining of bilateral lower extremity pain. Patient (Resident 1) reportedly was just discharged from (Facility name) this morning. She was driven to her apartment where she was unable to walk into the apartment." The facility admission agreement signed by Resident 1 on 9/5/16, indicated "The only reasons that we can transfer you to another facility or discharge you against your wishes are: 4) You have not paid for your stay in our Facility or have not arranged to have payment made under Medicare, Medi-Cal, or private insurance. If we participate in Medi-Cal or Medicare, we will not transfer you from the Facility or discharge you solely because you change from private pay or Medicare to Medi-Cal payment." This failure had a direct relationship to the health, safety, or security of patients. |
| 120000328 |
The Rehabilitation Center of Bakersfield |
120012980 |
B |
7-Mar-17 |
M1ZO11 |
1953 |
Health and Safety Code 1418.91 (a)(b)
(a) A long-term health care facility shall report all allegations of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.
(b) A failure to comply with the requirements of this section shall be a class "B" violation.
Based on interview and record review, the facility failed to report to the Department an allegation of neglect. This had the potential for other allegations of neglect not to be investigated and to go unreported.
During an interview with the Director of Staff Development (DSD), on 1/18/17, at 1:25 PM, the DSD stated she could not remember the date when Certified Nursing Assistant (CNA) 1 informed her she had placed a towel under her residents so she would not have to change the residents twice during her shift. The DSD stated what CNA 1 did to the residents was not acceptable. The DSD was asked if this incident (allegation of neglect) was reported to California Department of Public Health (CDPH). The DSD stated to ask the Assistant Director of Nursing (ADON).
During an interview with the ADON, on 1/18/17, at 1: 50 PM, the ADON she was not fully aware of the incident. The ADON stated Registered Nurse (RN) 1 knew what happened regarding this incident.
During an interview with RN 1, on 1/18/17, at 1:53 PM, RN 1 stated she was not aware CNA 1 placed a towel under her residents.
During an interview with the Director of Nursing (DON), on 1/18/17, at 2:28 PM, he was informed there was no evidence the facility reported the incident to CDPH. No further information was provided.
The facility policy and procedures titled "Abuse-Reporting & Investigation," revision date 11/2016, indicated under Policy, "The facility will report all allegations of abuse as required by law and regulations to the appropriate agencies."
Therefore, the facility failed to report an allegation of abuse to the Department within 24 hours. |
| 220000085 |
THE SEQUOIAS |
220011317 |
A |
11-Mar-15 |
BUND12 |
3964 |
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. This Requirement is not met as evidenced by: Based on interview and record review the facility failed to implement interventions to reduce accident hazards and risks when : 1. Seven of 32 licensed staff (Director of Nurses (DON), Nurse Manager (NM), Registered Nurse (RN 6), Licensed Vocational Nurse ( LVN 1, 4 and 5 ) and Certified Nurse Assistant (CNA 6) were not trained on mechanical lift manufacturer's operational manual transfer and techniques recommendations.2. 31 of 32 licensed staff (DON; NM; RN 2 RN 3; RN 4; RN 5; RN 6; LVN 1; LVN 2; LVN 3; LVN 4; LVN 5; LVN 6; LVN 7; CNA 1; CNA 2; CNA 3; CNA 4; CNA 5; CNA 6; CNA 7; CNA 8; CNA 9; CNA 10; CNA 11; CNA 12; CNA 13; CNA 14; CNA 15; CNA 16; CNA 17) were not inserviced after revision of resident care policy and procedure.Failure to train staff in proper transfer technique could potentially result to fall incidents during mechanical lift transfers of residents.Findings: During interviews on 3/20/15 at 1 PM, the NM stated that there were three residents (Residents 1, 2 and 3) who a needed mechanical lift for transfers. LVN 1 was in charge of staff providing care for residents on the North Side section of the facility for 3/20/15 morning shift. During an interview on 3/20/15 at 2:30 PM, LVN 1 concurred he was the MDS (Minimum Data Set- a resident assessment tool) coordinator.During interview on 3/20/15 at 4:PM, the interim DON stated she was responsible for monitoring implementation of interventions for the mechanical lift slings.During a interview on 3/20/15 at 4:10 PM, the DSD stated training for direct care staff were based on facility accident prevention policy and procedures and the mechanical lift device manufacturer's operational manual recommendations.Review of document titled, "Health Center Licensed Nurses", received 3/20/15, indicated the facility had seven RNs, seven LVNs and 17 CNAs on the licensed staff roster. The interim DON and the interim NM were not included on the licensed staff roster list.Review of document titled, Resident Care Policy and Procedure, titled, "Safe Resident Transfers", revised 3/17/15, indicated, "Purpose- To ensure the safety of residents and staff by using safe handling and movement techniques and maintaining a "Culture of Safety" approach to safety in the work environment. Policy... shall ensure the safety of residents and staff by utilizing safe handling and movement techniques for residents that maintain a safe work environment for staff... mechanical lifting equipment and/or approved resident handling aids shall be used to prevent the manual lifting and handling of residents... Procedure... C. Staff shall complete training and demonstrate competency in ... safe resident handling and movement tasks and mechanical lifting device equipment and processes for sling inspections and use... D. Mechanical Lifting Devices and other equipment /aids... Slings that show damage will be turned in to the Director of Nurses and replaced..." Review of Inservice Education Records, dated 9/11/14; 12/15/14; 2/20/15; 2/24/15 and 3/14/15 had no documentation that the DON , NM, RN 6, LVN 1, LVN 4, LVN 5 and CNA 6 attended mechanical lift manufacturer's operational manual recommendations' transfer techniques training.Review of Inservice Education Records, dated 9/11/14; 12/15/14; 2/20/15; 2/24/15 and 3/14/15 indicated no inservice training was done for 31 of 32 licensed staff regarding Resident Care Policy and Procedure, titled, "Safe Resident Transfers", revised 3/17/15.During interview on 3/20/15 at 6 PM, the interim Administrator concurred inservice training for the use of the mechanical lift device according to the manufacturer's operations manual was not complete. |
| 230000255 |
Twin Oaks Post Acute Rehab |
230009230 |
B |
07-Jun-12 |
ZBRU11 |
7197 |
483.12(a)(4)-(6) Notice Requirements Before Transfer/Discharge Before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; record the reasons in the resident's clinical record; and include in the notice the items described in paragraph (a)(6) of this section. Except 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. Based on observation, interview, and record review, the facility failed to document in the medical record the reasons for the anticipated discharge of Resident 1, when the facility gave Resident 1 a discharge notice. This had the potential for Resident 1 to suffer anxiety or emotional harm from being discharged involuntarily from the facility. Resident 1 was a 58 year old male admitted to the facility on 4/1/12 with diagnoses that included right and left ankle fractures and alcohol dependency. The facility's nursing admission evaluation, dated 4/1/12, described Resident 1 as alert, cheerful, and oriented to person, place, and time. During an observation on 4/13/12 at 1:40 pm in Resident 1's room, he was sitting up in a wheelchair with both legs extended. External fixation hardware was in place on both ankles which were supported on pillows. He was dressed in a shirt and short pants. (External fixation hardware is a combination of large pins and rods. The pins are drilled through the skin into the bone and held in place by the rods to temporarily stabilize a fracture. External fixation is used when there is too much swelling for surgical repair of the fracture or a cast.) During an interview with Resident 1 on 4/13/12 at 1:40 pm, he stated that he was given a notice for discharge on 4/12/12. He stated that he was upset about being told he was to be discharged because he did not know the reason why. Resident 1 stated that he thought the reason for discharge was because of the bad behavior of his now ex-friend during a recent visit to the facility. Resident 1 stated that during the visit his friend cussed and was very loud. Resident 1 also stated that the address on the notice was not his home address, but that of his ex-friend. Resident 1 was upset about being discharged to his ex-friend's home and distressed about where he was to go after his discharge. He stated that he had no other place to go, but he did not want to go to his ex-friend's house.The clinical record for Resident 1 was reviewed on 4/13/12. The Behavior Evaluation and Review, dated 4/2/12, indicated that Resident 1 was at risk for changes in his mood state because of the new environment. A care plan titled "Behavioral Symptoms," dated 4/3/12, indicated that Resident 1 behavioral symptoms were manifested by profanity, agitation, and sexual statements made towards female staff.Documentation in the nurse's notes was reviewed on 4/13/12. An entry, dated 4/6/12, at 11:45 pm indicated, "Resident very upset off and on tonight. Using foul language, throwing things in room. Ripped off shirt and dropped cell phone in toilet." Another note, dated 4/11/12 at 10:30 am, indicated, "Paged to resident's room due to outburst which included verbal and physical inappropriate behavior; upon entering resident's room, noted bedside dresser tipped forward with all drawers open/empty and personal items scattered throughout room wall-to-wall. All bedding bundled up with additional personal items within." The note indicated that when Resident 1 was asked about his room, he answered, "I guess I might have tossed some things because you guys made the dresser fall over and ruined my phone." Another note, dated 4/11/12 at 10 pm, indicated, "Resident had male visitor in room and both men were yelling and cursing and being inappropriate. ... asked not to yell or curse because it scares other residents."A Notice of Proposed Transfer/Discharge, dated 4/12/12, indicated that Resident 1 was notified on 4/12/12 that he would be discharged from the facility on 5/12/12. The reason on the notice given by the facility for his discharge was, "The transfer or discharge is necessary for your welfare and your needs cannot be met in the facility." There was no documentation in the clinical record by a physician or any other staff that explained why Resident 1's needs could not be met by the facility or why the discharge was necessary.The clinical record for Resident 1 was reviewed on 4/13/12. Nurse's notes, dated 4/12/12 at 9 pm, indicated, "Resident ... is very sad tonight he was told he has to leave in 30 days." During an interview with Administrator B on 4/13/12 at 3 pm, she stated that Resident 1 was given the notice for discharge because he was scheduled to go to the acute hospital for surgery on 4/16/12. Administrator B stated that she was told by the acute hospital that unless there was a previous intent of discharge from the long term facility, the facility would have to take Resident 1 back after his surgery. She stated that she was unaware that there needed to be documentation by a physician in the resident's medical record to support the facility's reason for Resident 1's discharge. Therefore, the facility failed to have documentation in Resident 1's medical record that supported the reason for his discharge from the facility as indicated on the Notice of Proposed Transfer/Discharge.This violation caused or occurred under circumstances likely to cause significant anxiety or other emotional trauma to Resident 1. |
| 230000255 |
Twin Oaks Post Acute Rehab |
230009415 |
B |
08-Apr-13 |
RGUM11 |
8559 |
F 323 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 monitor and supervise one of three residents when his low blood pressure increased his risk for falling and notify the physician of continued orthostatic hypotension (sudden fall in blood pressure) symptoms. This resulted in a fall and a hip fracture requiring surgery for Resident 1. Resident 1 was first admitted to the facility on 5/10/11, following a stay at an acute care hospital where he had been treated for diagnoses that included acute renal failure (rapid onset of failure of the kidneys; dual organs that filter waste from the blood and send waste out with urination) with chronic kidney disease (CKD) and a history of diabetes (inability to control the building up of sugar in the blood), enlarged prostate (a gland next to the urinary bladder that when enlarged can cause an urgency to urinate), urinary tract infection (bacteria in the bladder and/or kidneys), and multiple cardiovascular (heart and blood vessel) disease processes. He had received three hemodialysis treatments (HD; the process of cleansing the blood of waste by sending the blood through a filtering machine, and where blood volume is reduced). According to the National Institute of Health website (www.nhlbi.nih.gov; www.ninds.nih.gov), a normal range for blood pressure (BP) is from 120/90 to 90/60, and "orthostatic hypotension is a sudden fall in blood pressure that occurs when a person assumes a standing position... It may be caused by hypovolemia (a decreased amount of blood in the body), from the excessive use of diuretics (medications to reduce excess fluids), vasodilators (medications used to lower the BP)...or medical conditions such as diabetes. Symptoms, which generally occur after sudden standing, include dizziness, lightheadedness, blurred vision, and syncope (temporary loss of consciousness)." In a "Discharge Summary" from the acute care hospital, dated 5/10/11, the physician dictated that Resident 1 had diagnoses of "Orthostatic hypotension and presyncope (dizziness preceding fainting) due to blood pressure medications." It also specified that particular medications and dosages were changed to improve the blood pressure problem.A discharge medications list that came from the acute care hospital, dated 5/10/11, read, "Dosage change" for Lasix (a diuretic) and for metoprolol (to prevent hypertension, high blood pressure), seven new medications were started; and eight other medications were stopped. The facility's standard admission orders, dated 5/10/11, included, "Rehabilitation potential: Good", and listed Resident 1's medications including Aldactone (aids in the elimination of excessive body fluids), and Lasix, Flomax (to improve the flow of urine by relaxing the enlarged prostate), and metoprolol. Orders also included that Resident 1 was to have his blood sugar level checked three times a day before meals and at bedtime, to receive insulin (to reduce blood sugar) as needed, and was to continue HD three times a week. According to the Nursing Drug Handbook (2010), and per Lexi-comp-Online (a nationally recognized drug information resource), Aldactone, Lasix, Flomax and metoprolol each carry warnings of two or more adverse side effects of dizziness, fatigue, orthostatic hypotension, weakness, vertigo (disabling sensation of surroundings spinning or tilting), confusion, lethargy (mental and physical sluggishness), ataxia (shaky movements and unsteady walking), asthenia (loss of strength), syncope (fainting), and somnolence (trance-like sleepiness). All four medications have an alert to carefully monitor for a drop in BP, which can lead to these adverse effects. A physical therapy evaluation, dated 5/11/11, for Resident 1, read, "impairments...contractures (stiffing of joints and loss of strength and mobility) in both hands, stiffness in both knees, forward-flexed posture, shaky movement control, functional decline, and poor energy."On 5/11/11, the physical therapist documented in his notes, "With treatment (HD) today, patient became dizzy upon arising. Patient has had orthostatic hypotension in hospital. Monitor."A fall risk evaluation form for Resident 1, dated 5/12/11, had an incomplete assessment of 11 of the 12 items listed under evaluation of "Gait/Balance." The only item assessed was that Resident 1 required the use of an assistive device for mobility. In the section, "Medications", no additional point was added for, "a change in medication and/or change in dosage...." Under evaluation of "Predisposing Diseases" the nurse documented "0". The incomplete assessment resulted in Resident 1 being scored at "low risk" for having a fall.A "Fall Risk" care plan (CP), dated 5/12/11, did not include Aldactone among the listed medications, listed no diagnoses, instructed staff to, "monitor for dizziness/vertigo" and "monitor blood pressure each week." The "Vital Sign" record showed BP checks for Resident 1, with no time specified, 115/79 on 5/10/11, 116/69 and 125/75 on 5/11/75, and 93/61 on 5/12/11. A night shift nursing note, dated 5/13/11 at 2 am, documented Resident 1's blood pressure as 98/54.On 5/13/11, after Resident 1 had received an HD treatment, a physical therapist assistant (PTA) A documented in the nurses notes, "During skilled physical therapy treatment patient twice displayed orthostatic hypotension with BP: sitting 93/60 and standing 67/48, returned resident to bed, report to nursing, later in day BP: supine 112/66 and sitting 80/49. " During an interview with PTA A on 6/8/12 at 9:30 am, PTA A stated that he had attempted physical therapy with Resident 1 at approximately 3:30 pm on 5/13/11. He stated that when Resident 1 could not safely proceed, he took him back to his bed and reported directly to the registered nurse in charge. The fall risk care plan was not updated following the night shift nurse's notes or PTA A's reporting of Resident 1's low blood pressures on 5/13/11.During an interview on 5/24/12 at 12:50 pm, PT F stated that safety awareness, impaired vision, very poor hearing, poor balance with legs that bowed out, and drops in blood pressure, particularly following HD, were all problems for Resident 1 from "when he first got here." During an interview on 6/7/12 at 2:35 am, PT Manager H stated that Resident 1 was non-compliant with instructions as he did not want to "bother" anybody by requesting assistance. She agreed that having an enlarged prostate could bring on an urgent need to stand to urinate, and that the side effects of many of his medications possibly contributed to his confusion.On 5/13/11 at 10:00 pm, Registered Nurse (RN) B noted, "at [9:15 pm] heard CNA (Certified Nursing Assistant) yelling for help - ran to Rm 312 and saw resident on floor on his left side...skin tear to left forearm...resident complained of severe left hip pain and was unable to move lower extremity...medics called and resident sent to emergency room. Resident stated he got dizzy. PT reported earlier in shift that resident was having orthostatic hypotension. Resident was reminded to sit up slowly and use call light before getting up." On 5/13/11 there were no nursing notes from RN B prior to Resident 1's fall, and there were no updates on Resident 1's Fall Risk care plan regarding hypotension.During an interview on 6/15/12 at 1:50 pm, RN B acknowledged that she did not check Resident 1's BP and did not report the information from the PTA A to the physician during the five+ hours preceding his fall on 5/13/11. According to the emergency room physician's admitting "History and Physical," dated 5/14/11, Resident 1 was diagnosed with a left hip fracture as a result of a fall.During interviews on 5/25/12 at 3:20 pm and 7/13/12 at 5 pm, the contributing factors that placed Resident 1 at high risk for falls were discussed with DON C and Administrator D. Resident 1 was not monitored by the nurse and that the physician was not notified of his low BP in the five+ hours prior to his fall on 5/13/11. Therefore, the facility failed to monitor and supervise Resident 1 when his low blood pressure increased his risk for falling and notify the physician of continued orthostatic hypotension symptoms. This resulted in a fall and a hip fracture requiring surgery for Resident 1 which had a direct or immediate relationship to the patients' health, safety, or security. |
| 230000197 |
Trinity Hospital D/P SNF |
230009534 |
B |
07-May-13 |
M2QC11 |
4334 |
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 ensure Patient 1 was free from verbal and physical abuse when Certified Nursing Assistant (CNA) A grabbed Patient 1's wrists and shouted in her face. This violated Patient 1's right to be free from abuse and had the potential to violate all patients' right to be free from abuse. Patient 1 was admitted on 7/2/12 with a diagnosis of Alzheimer's disease. The most recent Minimum Data Set, an assessment tool, dated 7/12/12, reflected that Patient 1 had severely impaired cognition and decision making skills, resisted care, wandered, and exhibited disruptive behaviors daily. On 7/31/12, the facility reported to the California Department of Public Health that CNA A had physically grabbed Patient 1's wrists in an attempt to prevent the patient from hitting CNA B. On 8/7/12 at 3:10 pm, CNA B was interviewed. CNA B stated that on 7/30/12 at 5:45 pm, she was attempting to redirect Patient 1, who was trying to wander out of the long term care unit. Patient 1 became combative and hit her (CNA B) on the chest and shoulders. CNA B stated that CNA A saw Patient 1 hitting her and intervened by firmly grabbing Patient 1's right wrist. Patient 1 then began hitting CNA A with her left hand and CNA A firmly grabbed hold of the left wrist and physically restrained both wrists. CNA B stated CNA A then screamed in Patient 1's face, "It is not ok to hit, you know that." CNA B stated that Patient 1 "Gave up" and she was able to guide Patient 1 safely to her room.On 8/8/12 at 4:25 pm, CNA A was interviewed. CNA A stated that she intervened on 7/30/12, because she thought CNA B was afraid of Patient 1. CNA A stated that she "Spoke directly" to Patient 1 to "Obtain her attention." CNA B stated that Patient 1 was combative with her as well, and hit and kicked her, which left her bruised. CNA A stated that she "cupped" her hand around Patient 1's elbows to "Lead" her out of the corridor and back toward her room. On 8/8/12, the facility's policy and procedure titled, "ABUSE," Section 2. "TRAINING," dated 1/11, was reviewed. Paragraph "B" directed, "Staff will complete Annual Review which includes but is not limited to the following information: patient rights, abuse prevention, appropriate interventions to deal with aggressive behaviors, mandatory reporting procedure without fear of reprisal, how to recognize signs of burnout, frustration and stress that may lead to abuse, what constitutes abuse, neglect and misappropriation of property." On 8/30/12, a review of the facility's annual training lessons to guide staff on how to care for residents with Alzheimer and other dementias, was conducted.A lesson titled, "Caring for the Resident with Dementia" instructed staff to, "Redirect, remain calm, and use comforting, non-controlling statements," when approaching a resident with dementia. A lesson titled, "Catastrophic Reactions," page 4, instructed staff to, "Use a soothing voice and touch to calm them." Page 9 read, "It is not helpful to try to explain the situation to the resident as he or she does not have the mental capacity to understand. Instead, stop the activity, speak and behave in a calm manner, and try to distract the resident."On 8/8/12 at 5:15 pm, the Director of Nursing (DON) was interviewed. The DON stated that during the alleged abuse investigation, CNA A had expressed to her, "We have rights too, we can protect ourselves" and "I wasn't going to let her [Patient 1] hit my co-worker." The DON confirmed that CNA A had not followed the facility's abuse protocol, and had not met the facility's expectations on how to care for a patient with Alzheimer/dementia, when CNA A physically restrained Patient 1's wrists and screamed in her face. Therefore, the facility failed to ensure that Patient 1 was free from verbal and physical abuse when CNA A grabbed Patient 1's wrists and shouted in her face. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to patients. |
| 230000255 |
Twin Oaks Post Acute Rehab |
230009692 |
B |
28-Mar-14 |
WWW911 |
4191 |
483.13(b), 483.13(c)(1)(i)FREE FROM ABUSE/INVOLUNTARY SECLUSION The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility failed to protect Patient 1 from verbal abuse by Certified Nurses Aide (CNA) B when he came into Patient 1's room and stood next to his bed and pointed his finger at Patient 1 and called him a "c__k s__ker" as he was leaving the facility on the last day of employment at the facility. The facility failed to ensure Patient 1's right to be free from verbal abuse. Patient 1, an 83 year old male was admitted to the facility on 4/7/11 with the following diagnoses: fluid overload; shortness of breath; anxiety; and insomnia. According to the Minimum Data Set (a patient assessment tool) Patient 1 was alert and oriented and able to make his needs known and his health care decisions. He required limited to extensive assistance with care. On 1/3/13 at 9:30 am, Patient 1 was interviewed and stated on 12/30/12 at 10:30 pm, CNA B came into his room, stood by his bed, pointed his finger at him and told him that "you were the worst 'c__k s__ker' I have ever taken care of." Patient 1 stated that he was very upset because he had been nearly asleep and that CNA B was beyond being rude to him. The more Patient 1 thought about the incident, he was worried about the other patients in the facility and how CNA B might be treating them, so he reported the incident to a Licensed Nurse, he could not remember her name. Patient 1 stated he was not aware that evening had been CNA B's last night working at the facility.Patient 1 described CNA B as being argumentative, derogatory and intrusive while providing his care. CNA B would not listen to him, he would go out of his way to argue with him and leave before completing Patient 1's requests. Patient 1 stated he had problems with sleeping and would find himself napping throughout the day and evening prior to going to bed. On the evenings CNA B worked whether he was assigned or not to Patient 1, he would abruptly stand at his doorway and shout "Is there anything I can do for you?" or "Hey old man do you want anything?" without seeing if he was napping. The yelling startled and woke Patient 1 up, making him confused and angry. Patient 1 had reported CNA B's behaviors to nursing (he could not remember the Licensed Nurses name) and CNA B was removed from his care for about two weeks within the past year, but then returned related to staffing issues he was told by CNA B.On 1/3/13 at 3:50 pm, CNA C was interviewed. She stated she had taken care of Patient 1 many times and the "secret to his care was to really listen to his requests." CNA C stated she had told CNA B to stop antagonizing Patient 1 by yelling from the doorway at the patient even when he could see CNA C was taking care of him. On 1/3/13 at 2 pm, Licensed Nurse (LN) D was interviewed. She stated CNA B could be very demanding and had an abrupt, demeaning attitude towards her and other staff. He did not work well with others, refusing to assist them when he was asked. She was not aware of the issue between Patient 1 and CNA B, or she would have reported the issue to her supervisor. On 1/3/13, CNA B's personnel file was reviewed. His letter of resignation was written on 12/22/12 stating that 12/30/12 would be his last day of work. In an interview on 1/3/13 at 4 pm, Director of Nursing (DON) denied that she was aware of the conflict between Patient 1 and CNA B, but Staff Development (DSD) stated that she knew there had been a conflict between Patient 1 and CNA B. The facility's investigation showed that Patient 1 made many complaints concerning his care by nursing staff. Therefore, the facility failed to protect Patient 1 from verbal abuse by CNA B when he came into Patient 1's room and stood next to his bed and pointed his finger at Patient 1 and called him a "c__k s__ker" as he was leaving the facility on the last day of employment at the facility. The facility failed to ensure Patient 1's right to be free from verbal abuse.This violation of this regulation had a direct relationship to the health, safety, or security of the residents. |
| 230000197 |
Trinity Hospital D/P SNF |
230010245 |
B |
20-Feb-14 |
FRLZ11 |
4343 |
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 prevent verbal abuse for Patient 1, when Certified Nursing Assistant (CNA) A used foul language and a demeaning statement while assisting Patient 1 with incontinence (uncontrolled urination) care. This failure had the potential for Patient 1 to suffer psychosocial harm such as loss of respect and dignity and had a direct relationship to the health, safety, or security of patients.Patient 1 was admitted to the facility on 1/15/03 with diagnoses which included senile dementia and depressive disorder. Patient 1's record was reviewed on 10/17/13. Patient 1 was not his own decision maker. A Minimum Data Set (MDS), an assessment tool, dated 10/16/13, indicated Patient 1 had moderately impaired decision making, usually understood others, was normally able to recall staff names and faces, and was completely dependent on staff assistance for personal hygiene and bathing. Patient 1's nursing care plan, dated 7/13/13, indicated Patient 1 had a need to sexually express himself at times, and the nursing staff would provide privacy for him. The Department of Public Health received a "Report of Suspected Verbal Abuse," dated 10/8/13, submitted by the Director of Nurses (DON) of the Skilled Nursing Facility. The report alleged that on 10/7/13, CNA A had verbally abused Patient 1 while changing his brief. The facility policy titled, "Abuse," dated as approved 9/3/13, was reviewed and indicated, under the definition of abuse, "This presumes that instances of abuse of all persons, even those in a coma, cause physical harm, or pain or mental anguish." It further defines verbal abuse to "...include disparaging and derogatory terms to persons ... regardless of their age, (or) ability to comprehend." It also indicated mental abuse, includes "humiliation." During an interview with Licensed Vocational Nurse (LVN) D, on 10/17/13 at 10:45 am, she stated Patient 1 was unable to converse; he only makes the same repetitive two word phrase every day in response to any statement made to him. She stated Patient 1 was unable to verbally make his needs known.During an interview with Certified Nurse Assistant Student (CNS) B on 10/17/13 at 11:15 am, she stated she was present in Patient 1's room on 10/7/13, when staff member CNA A was changing the brief for Patient 1. CNA A told two Certified Nurse Assistant students (using crude terminology) that Patient 1 had sexually relieved himself yesterday in his room, and while CNA A looked directly face to face with Patient 1 she admonished, "It was f_ _ king (expletive) disgusting!" CNS B stated as she looked at Patient 1, she perceived a "sad" look in his eyes. CNS B stated, "My heart hurt" because of what CNA A had said to Patient 1 as it was humiliating, and she was embarrassed for him. During an interview with Certified Nurse Assistant student (CNS) C on 10/17/13 at 11:30 am, she stated CNA A had acknowledged she was aware it was the patients right to have a sexual outlet, but CNA A had mistreated Patient 1 when she had bent down and got "right in his face," and looking him in the eye, said in an aggressive tone that his behavior was "Disgusting!" CNS C stated CNA A's language was vulgar and she felt sorry for Patient 1. During an interview with the DON on 10/17/13 at 10:30 am, she stated that she had investigated the allegation of verbal abuse, and based on her investigation determined that CNA A was abusive to Patient 1 and violated the facility policy. She stated CNA A had been reported to the registry and would not be allowed to return to the facility because of her treatment of Patient 1. Therefore, the facility failed to prevent verbal abuse for Patient 1, when Certified Nursing Assistant (CNA) A used foul language and a demeaning statement while assisting Patient 1 with incontinence (uncontrolled urination) care. This failure had the potential for Patient 1 to suffer psychosocial harm such as loss of respect and dignity.This violation had a direct relationship to the health, safety, or security of patients. |
| 230000255 |
Twin Oaks Post Acute Rehab |
230010658 |
B |
15-Jun-15 |
1PXY11 |
9407 |
T22 DIV5 CH3 ART5-72527(a)(5)(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: (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). T22 DIV5 CH3 ART5-72528(b)(1-6) (b) The information material to a decision concerning the administration of a psychotherapeutic drug or physical restraint, or the prolonged use of a device that may lead to the inability of the patient to regain use of a normal bodily function shall include at least the following: (1) The reason for the treatment and the nature and seriousness of the patient's illness.(2) The nature of the procedures to be used in the proposed treatment including their probable frequency andduration.(3) The probable degree and duration (temporary or permanent) of improvement or remission, expected with or without such treatment.(4) The nature, degree, duration and probability of the side effects and significant risks, commonly known by the health professions.(5) The reasonable alternative treatments and risks, and why the health professional is recommending this particular treatment.(6) That the patient has the right to accept or refuse the proposed treatment, and if he or she consents, has the right to revoke his or her consent for any reason at any time. T22 DIV5 CH3 ART5-72528(c) (c) Before initiating the 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, facility staff shall verify that the patient's health record contains documentation that the patient has given informed consent to the proposed treatment or procedure. The facility shall also ensure that all decisions concerning the withdrawal or withholding of life sustaining treatment are documented in the patient's health record.The facility failed to ensure that informed consent was obtained from Resident 1's responsible party prior to the facility starting Resident 1 on an antipsychotic medication (Perphenazine). The resident was taking the antipsychotic medication (a class of drugs used to treat psychosis and other mental and emotional conditions) for five weeks, when he fell in his room sustaining a right broken hip. The Federal Drug Administration (FDA) issued an FDA alert on 6/16/2008 to healthcare professionals that stated, "Perphenazine is not indicated for the treatment of dementia-related psychosis and that there is an increased risk of mortality in elderly patients treated for dementia-related psychosis."The FDA also had a black box warning for this drug (a black box warning is issued by the U.S. Food and Drug Administration and featured in the labeling of drugs associated with serious adverse reactions). After his fall, Resident 1 was admitted to the hospital for treatment of his broken hip, where he died 19 days later.Resident 1 was an 87 year old male, who was admitted to the facility on 9/21/11 with diagnoses that included encephalopathy (a brain disorder that includes disease or malfunction). Later diagnoses included dementia with and without behavioral disturbances and psychosis of non-specific origin. The resident's Minimum Data Set (MDS-a standardized assessment), dated 1/15/14, indicated that he had an acute change in his mental status from the previous MDS, dated 9/29/13, about 3 1/2 months. The facility identified the resident's son on the face sheet as the Responsible Party (RP).Due to the resident having increasing episodes of behaviors, such as striking out at staff and wandering into other resident's rooms, the physician decided to order the antipsychotic drug, Perphenazine 2 mg (milligrams), three times per day on 2/3/14. The resident was also taking Depakote (a mood stabilizer) 500 mg every day (ordered 1/19/13), Ativan (an antianxiety drug) 0.5 mg twice per day, and Ativan 0.5 mg every 12 hours, as needed (both ordered 2/21/14).In an interview with the physician on 3/26/14, he said he would have gotten informed consent from the family before he started the medication, but could not recall the specific conversation with the RP, nor what he reviewed about the drug, the risks versus benefits, the side effects, or anything specific. He stated, "I would have (gotten it), I can't remember. I have four nursing homes that I am Medical Director for. I do not agree that families should be asked if they thought their loved ones should receive a medication, as that is my job." Resident 1's medical record contained a signed informed consent from the physician indicating that he did speak with the RP.During a telephone interview with Resident 1's RP on 3/26/14, and again, on 4/2/14 in person, he stated, "No, he (the physician) did not discuss any of the meds (medications) with us. No one ever told us the risk versus the benefits of using the medication. I would never have agreed to the use of the anti-psychotic drug if I had known the side effects." He further stated that the nursing staff would call to let him know that the facility was putting "dad on medication for his behaviors but they definitely did not tell me the risks or benefits, nor side effects."The facility's informed consent policy titled, "CA Informed Consent for Medications (Title 22)," updated 9/13, read, "When the physician has ordered the use of Anti-Psychotic, Anti-Depressant, Anti-Anxiety and/or Sedative/Hypnotic Medication(s), the Nursing Center does not administer medication until verification that the physician has obtained informed consent from the Resident and/or Resident's Authorized Representative."An interview was conducted on 3/26/14 at 9:30 am and 3:45 pm with MDS Nurse J, the Licensed Nurse who signed the CA Verification of Resident Informed Consent for Psychotherapeutic Drugs. She stated that she was in an IDT (Interdisciplinary Team) meeting discussing the increased behaviors that Resident 1 was exhibiting and was asked by the team to contact the physician, which she did. She stated, "my signature on the informed consent form for Perphenazine only meant that I took the order, not that I verified with the physician that he got informed consent."The form has the following statement followed by a signature line: Prescriber has verbally indicated that consent has been obtained. MDS Nurse J stated that her signature on that line only meant that she obtained the order for the anti-psychotic drug and that she did not ask the physician if he obtained informed consent. MDS Nurse J indicated that she does not work on the nursing stations, as she is the MDS nurse, and she was not aware that the form had that line in it.The U.S. Food and Drug Administration (FDA) issued black box warnings for all antipsychotic drugs stating that they greatly increase the risk of death for elderly persons with dementia-related psychosis.The FDA issued an advisory in June 2008 to healthcare professionals that stated: Elderly patients with dementia-related psychosis treated with conventional or atypical antipsychotics drugs are at an increased risk of death. Antipsychotic drugs are not approved for the treatment of dementia-related psychosis. Furthermore, there is no approved drug for the treatment of dementia-related psychosis. Health care professionals should consider other management options. Because Resident 1 was prescribed an antipsychotic drug without consent, this presented (1) an imminent danger that death or serious harm to the resident would result, or (2) substantial probability that death or serious physical harm to the residents would result. Therefore, the facility failed to ensure that informed consent was obtained from Resident 1's responsible party prior to the facility starting Resident 1 on an antipsychotic medication (Perphenazine). The resident was taking the antipsychotic medication (a class of drugs used to treat psychosis and other mental and emotional conditions) for five weeks, when he fell in his room sustaining a right broken hip. The Federal Drug Administration (FDA) issued an FDA alert on 6/16/2008 to healthcare professionals that stated, "Perphenazine is not indicated for the treatment of dementia-related psychosis and that there is an increased risk of mortality in elderly patients treated for dementia-related psychosis."The FDA also had a black box warning for this drug (a black box warning is issued by the U.S. Food and Drug Administration and featured in the labeling of drugs associated with serious adverse reactions). After his fall, Resident 1 was admitted to the hospital for treatment of his broken hip, where he died 19 days later.The violation of this regulation had a direct or immediate relationship to the health, safety, or security of residents. |
| 230000255 |
Twin Oaks Post Acute Rehab |
230010660 |
A |
15-Jun-15 |
1PXY11 |
6307 |
F309 - 483.25 Provide Care/Services for Highest Well BeingEach resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.The facility failed to provide Resident 1 with the necessary services to attain his highest practicable physical well-being, in accordance with his plan of care, which required that the resident have a staff member with him at all times. Resident 1 was found on the floor in his room with a broken hip on 3/11/14 at 5:30 am, when the assigned staff member left Resident 1 unattended, and left the room to help another staff member. Resident 1 succumbed to his injuries sustained in the fall, and died 19 days later in the hospital.Resident 1's record was reviewed during an investigation of an entity reported incident. Resident 1, an 87 year old male, was admitted to the facility on 9/21/11 with diagnosisthat included encephalopathy (a brain disorder that included disease or malfunction). Later diagnoses included dementia with and without behavioral disturbances and psychosis of non-specific origin. An interview was conducted and Resident 1's record was reviewed with the Assistant Director of Nurses (ADON) on 3/17/14 at 10:00 am. The ADON stated that Resident 1 became aggressive and agitated after his wife (also a resident in the facility) was moved from his room to another wing in the facility on 12/31/13. She confirmed that the resident began to wander into other resident's room and he became more aggressive and combative to staff (striking out at staff) as they tried to redirect him. The ADON stated that the IDT (Interdisciplinary Team) decided to "put the resident on a 1:1 staffing from 1:00-7:30 pm starting 1/14/14" which meant that one direct care staff (CNA-Certified Nurse Assistant) would "stay with the resident at all times between 1:00-7:30 pm." According to IDT notes dated 2/1/14, the 1:1 supervision was increased from 1-7:30 pm to 24 hours per day because the "resident has been attempting to wander in the early morning into others (residents) rooms." The ADON confirmed on 3/17/14 at 10:00 am that Resident 1 was placed on 24 hour 1:1 supervision with a CNA. The ADON stated that the resident was not to be left alone at any time. Review of a Fall Risk care plan, dated 1/21/14, indicated Resident 1 was at high risk for falls due to disorientation and confusion, medications, previous falls, and problems with balance, coordination and walking. During an interview with CNA A on 3/18/14 at 6:10 am, she stated that she worked the night shift, starting at 10:30 pm on 3/10/14 and ending at 6:30 am on 3/11/14. She was assigned to care for Resident 1 on that shift, as her only resident. She explained that Resident 1 was a 1:1, which meant that Resident 1 was the only resident she was assigned to provide services for and watch during her shift. She stated that Resident 1 had been identified as having multiple behaviors and that she would re-direct him, as his behavior dictated. She stated that the resident had been up most of the night, making his bed and wandering around the room. "I got him changed and cleaned up and he laid down about 4:30-4:45 am. I thought he was asleep. I left the room to help CNA B get other residents out of bed. I was only gone about 20 minutes and when I went back in the room with Licensed Nurse (LN) C, we found him on his back on the floor. This (CNA A found Resident 1 on the floor) happened about 5:30 am. I never should have left him; I never should have left him." During the same interview on 3/18 at 6:10 am, CNA A acknowledged that relief staffs were assigned so she could take her breaks and not leave Resident 1 alone. LN C, the charge/medication nurse, was interviewed on 3/18/14 at 6:35 am. She stated she thought CNA A was in Resident 1's room with him, as his door was shut. She was giving medications across the hall from Resident 1's room. "I found out that CNA A had left Resident 1's room to assist CNA B. I went into Resident 1's room right after CNA A did and found Resident 1 on the floor. CNA A should never have left the resident alone as she was assigned to him as a 1:1." In an interview with CNA B on 3/18/14 at 6:45 am, she stated that 1:1 means "not to leave the resident."Interviews were conducted on 3/17/14 from 12 pm-1:40 pm with five CNA staff (CNAs D, E, F, G, H) who had been assigned on different shifts to care for Resident 1 from 3/7/14-3/10/14 as 1:1 care givers. These staff stated that a 1:1 meant that they were not to leave the resident alone at any time. They explained that another staff member was assigned to cover for them whenever they needed to take their meal or other breaks.In an interview with Administrative Staff 20 on 3/17/14 at 10 am, she stated that 1:1 means "staff stays in the room with the resident 24/7." In an interview with Administrative Staff 21 on 3/17/14 at 8:25 am, she stated that the facility does not have a policy or procedure for 1:1 staffing.Resident 1's record was reviewed with Administrative Staff 20 on 3/17/14 at 10:00 am. The MDS, dated 1/15/14, documented that Resident 1 was able to walk and transfer from his bed only with oversight supervision and set-up help from staff. The IDT (Interdisciplinary Team) Progress Note, dated 2/1/14 at 8:00 am, read, "1:1 to be re-implemented on NOC shift at this time." The Nursing Staffing Assignment and Sign-In Sheets for 3/10/14 were reviewed with Administrative Staff 22 on 3/17/14 at 12:15 pm. The staffing sheets showed that direct care staff were assigned an 1:1 for Resident 1, and that relief staff assignments were clearly indicated for each shift; day, evening, and night.Therefore, the facility failed to provide 1:1 staff supervision for Resident 1, in accordance with the plan of care, when CNA A left Resident 1 unattended in his room. During the time that CNA A was not in the room, Resident 1 fell and sustained a fractured right hip. Resident expired 19 days after the fall in the hospital.The violation of this regulation presented an imminent danger that death or serious harm to residents would result, or substantial probability that death or serious harm to residents would result. |
| 240000650 |
Terracina Post Acute |
240009030 |
B |
21-Feb-12 |
PCYD11 |
8968 |
REGULATION VIOLATION: Title 22 72311 Nursing Services General (a) Nursing services shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs, with input, as necessary, from health professionals involved in the care of the patient. Initial assessment shall commence at the time of admission of the patient and be completed within seven days after admission. AND(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.(3) Notifying the attending physician promptly of: (B) Any sudden and /or marked adverse change in signs, symptoms or behavior exhibited by the patient.The facility failed to do the following to provide an ongoing assessment by a registered nurse (RN) of Patient A's ability to chew and swallow when a certified nursing assistant (CNA) reported that the patient began "pocketing" food, which placed Patient A at increased risk of aspiration. The facility failed to notify the physician when Patient A first pocketed food and developed a fever after the completion of an antibiotic, which resulted in Patient A being hospitalized and placed on a ventilator (a plastic tube is inserted into the airway and attached to a machine that assists in the process of respiration)due to aspiration. On August 5, 2011 at 12:15 PM, an unannounced visit was made to the facility to investigate a complaint that Patient A had been found unresponsive with food in his mouth on June 26, 2011 and subsequently was taken to the acute care hospital (GACH 1), where he was placed on a mechanical ventilator (a plastic tube is placed in a person's airway and a machine delivers pressure to expand the lungs for breathing). Patient A's admission diagnoses to GACH 1 included: aspiration pneumonia (food or other foreign body inhaled into lungs), respiratory failure, (lungs not adequately getting oxygen to tissues); renal insufficiency (kidneys losing their functioning), history of a cerebral vascular accident (CVA-stroke) with left sided weakness, seizure disorder (convulsions) and dementia. Patient A was an 84 year old man who had been initially admitted to the facility in March of 2005. On June 17, 2011, after being sent to the emergency room (ER) with an altered level of consciousness (ALOC) and respiratory symptoms, Patient A was readmitted to the facility. Patient A's readmission diagnosis was urinary tract infection. Readmission orders included oxygen by nasal cannula to maintain his oxygen saturation levels 92%. On June 24, 2011, at 1:00 PM, the LVN documented, "Alert and in no respiratory distress...noted resident to pocket food (food is retained in the cheek instead of being chewed and swallowed placing patients at risk for choking) that is especially textured...however, does fine with liquids and pureed like foods. Unit leader is aware." There was no documentation that the physician was notified of this change in Patient A's condition.Patient A's diet order was a high protein, low sodium diet with fortified milk, juice and cereal. In addition, the patient received "2 Cal" (a liquid supplement) four times a day with medications and a 4 ounce health shake with meals.Documentation showed there had been no diet change since Patient A's return from the hospital on June 17, 2011. In addition, there was no documented evidence of a plan of care or speech evaluation to assess altering the texture of his food due to a risk of choking. A review of the physician order for the course of the antibiotic Bactrim indicated that the last dose was to be given on June 24, 2011. A review of the Nurses' Progress Notes dated June 17- June 25, 2011, indicated that Patient A was verbally responsive, had oxygen saturation levels ranging from 95-97 %, and had remained afebrile (no fever).On June 26, 2011 at 3:30 AM, two days after the completion of antibiotics, the nurse documented that Patient A had a sudden temperature of 105 degrees Fahrenheit (F) and was given Tylenol (a normal temperature is 98.6 F). When the nurse checked the temperature again at 6:00 AM, it was 100.4 F. There was no documented evidence of an assessment of the patient. The nurse documented, "will monitor."On June 26, 2011 at 11:00, documentation showed Patient A had an elevated temperature of 101.8 and was again administered Tylenol. At 12:00 PM, Patient A's temperature was 99.1 F. Again, there was no documented evidence that the physician had been notified of this change in condition. On June 26, 2011 at approximately 7:00 PM, a family member went to the nurses' station to tell the nurse that Patient A was not responding and had food in his mouth. A review of the licensed nurses notes for that time period indicated, "...informed resident not responding when she calls his name. Charge nurse did assessment and called "code blue" (Code Blue is used for respiratory or cardiac emergencies). Vital signs were: temperature 97.6 F, pulse-80, respirations-38(normal 12-20) and blood pressure-60/32 (normal -120/80). However, documentation did not included Patient A's blood sugar of 385 and his oxygen saturation of 92 %. In addition, there was no documented reference to Patient A having food pocketed in his mouth. During an interview with CNA 1 on August 5, 2011 at 2:00 PM, she stated, "I was feeding the patient and he wasn't really swallowing, pocketing his food but wouldn't open his mouth. I tried to get the food but he'd closed his mouth, so I'd leave the room. I'd go back and try to get a little more out. When the daughter came I was at the station and she told me about the food. I told her I had tried to get it out little by little so I got a tongue depressor and scooped out about a spoonful. It was pocketed in his cheeks. He didn't respond. I told the charge nurse..." When asked if he had taken liquids CNA 1 stated, "I put a cup to his mouth but liquid ran out, that's when I stopped feeding him." During an interview with the charge nurse (CN) on August 8, 2011, at 9:00 AM, the CN stated that he'd been at the nurses' station when the family came to tell him [Patient A] wouldn't respond. The CN stated, "That's when [CNA 1's name] told me that she tried to feed him but she had to clean food from his mouth. I went in after a couple minutes and I didn't see food and called Code Blue." The CN did not provide a rationale for calling the Code Blue. During further interview with the CN when asked about the entry regarding pocketing food that he had documented on June 24, 2011, the CN replied, "He had problems pocketing food." When asked why that information had not been included on the transfer sheet to the acute care hospital, he stated, "My mistake". During a review with the director of nurses (DNS) of Patient A's clinical record on August 6, 2001 at 11:00 AM, no documented evidence could be found that pocketing food had been an ongoing problem or had been assessed by the RN or the physician. There was no documented evidence that a speech therapist had been called in to assess Patient A's ability to chew and swallow to ensure the correct diet texture was prescribed for him. There was no nursing plan of care to address the potential for aspiration, or evidence of physician notification. These findings were confirmed by the DNS. During a review of the clinical record at the acute care hospital (GACH 2) where Patient A was sent on June 26, 2011, the patient's initial Glasgow Coma Scale (a scale used to give points for eye opening, verbal response and motor response ranging from a score of 3 to 15- the higher the number, the more alert the person is), was a "12" by the time he arrived at the ER after receiving hydration. The score had been only "3" upon arrival of the paramedics at the skilled nursing facility. Patient A's admitting diagnoses were: respiratory failure secondary to aspiration pneumonia, sepsis (bacteria in bloodstream), dehydration (lack of fluids in body), renal insufficiency (kidneys not functioning well), and lactic acidosis (caused from his respiratory and renal status). Patient A was placed on a ventilator in the ER and transferred to the intensive care unit for continued treatment. The facility's failure to conduct ongoing nursing assessments when the patient's problem of "pocketing" food was discovered placed Patient A at continued risk of aspiration of food. In addition, the facility's failure to promptly notify the physician when Patient A was discovered to pocket food and fever after a course of antibiotics, resulted in Patient A being hospitalized. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000905 |
TERRACE VIEW HOUSE |
240009319 |
B |
21-May-12 |
7TW311 |
5229 |
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. (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 A was protected from physical harm. On March 28, 2008, a male CNA physically abused Client A. Client A sustained injuries to his mouth and stomach.During an unannounced complaint investigation on April 08, 2008 at 5:55 AM, it was determined that the facility staff failed to treat a client with dignity and respect, which resulted in the client being subjected to physical abuse by a direct care staff member hired by the facility.Client A, a 36 year old male, was admitted to the facility on August 5, 1997. His diagnoses included cerebral palsy, spastic quadriplegia and seizure disorder. He was described in his Psychological Evaluation to be intellectually in the low to moderate range of mental retardation. Documentation included, "He [Client A] is reported to say a lot of words, and some complete sentences and ask questions, though his speech is slurred and difficult to understand."On April 08, 2008 at 6:05 AM, an interview was conducted with Client A. He stated, that the CNA had put him down hard in his wheel chair and then took him into the office and then hit him in the mouth and stomach. He also indicated with his hand where he was hit.On March 28, 2008 at approximately 6:00 A.M, as documented in the INTERDISCIPLINARY NOTES, a staff member walked into the home and went to clock in when she saw that the Client was alone in the office area. The note indicated the following, "I saw Client A's mouth and asked him what happened. The Client said that the CNA had punched him in the mouth and stomach."According to the INVESTIGATIVE REPORT, the QRMP arrived at the facility at 6:03 AM on March 28, 2008; it was documented that the facility's registered nurse and the sheriff had not arrived. The report noted that the Clients lower lip was cut, but not bleeding. The QMRP asked the client what happened; the Client responded, "[The CNA] got him out of bed and into his wheel chair, hard." It further revealed that "the CNA took him into the facility's office area and that the CNA "just hit him in the mouth and in the stomach with no apparent provocation or words said." The Client stated that he thought [the CNA] was mad (as manifested by his face), according to the clients recollection. The QMRP's note continued with an interview of the Facility Manager (FM) who told the CNA to leave the Facility; the FM noted that the CNA's response was "whatever" and the CNA clocked out. The Yucaipa Sheriff Department was called and an officer arrived on the scene at 7:30 on 03/28/08. Staff provided an address to the officer. The report also indicated that the facility received a call on 03/28/08 at 11:00 AM from the Sheriff's Department to notify them that they had found the CNA and had taken him to jail. A copy of the arrest report was obtained for the investigation, which indicated that the CNA was arrested at his residence, and booked for alleged felony dependant adult abuse on March 08, 2008 at approximately 9:05 AM.Review of the employee's employment file was conducted at the corporate main office. An employee termination report was completed with a termination date of March 31, 2008 for "an abuse allegation against Client A." "CNA was accused of punching a client on the stomach area and on the mouth." Additional review also revealed a State of California Department of Health Services, Nurse Assistant Certificate, number 00658105 with an effective date of October 07, 2005 and an expiration date of March 08, 2008.An interview was conducted with corporate staff on the firing of their employee on April 08, 2008 at 08:45 AM. They stated that they followed their policy on PROTECTION OF CLIENT DURING ABUSE INVESTIGATION. The staff said as soon as the Facility Manager was on site the employee was told to go home. In addition, staffs were asked how they track and verify employee licenses and certifications. Staff stated that they have a reminder system but she did not know if it was used for this CNA. When asked why this employee was allowed to work on an expired license there was no response.Based on interview, clinical and other record review, the facility failed to ensure that their client was treated with dignity and respect and free from physical abuse by an employee of the facility. Further review of the employee records indicated that the employee of the facility was working at the facility with expired Nursing Assistant Certification.These facility failures had a direct or immediate relationship to the health, safety, or security of long term health care facility patients or residents. |
| 240000650 |
Terracina Post Acute |
240009615 |
B |
28-Nov-12 |
0T4B11 |
19951 |
REGULATION VIOLATION: Title 42 F 314 483.25 (c) Pressure Sores and F 315 483.25(d)(2) Urinary Incontinence F 314 483.25(c) Based on the comprehensive assessment of a resident, the facility must ensure that-- (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility failed to ensure Resident 1 received the care to prevent the formation and progression of pressure ulcers, which would include providing the resident with accurate assessments, treatment care plan, evaluate treatment and revise the approaches to prevent deterioration of pressure ulcers and the development of additional pressure ulcers. ANDF 315 483.25(d)(2) Based on the resident's comprehensive assessment, the facility must ensure that-- A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.Based on observation, interview and record review, the facility failed to ensure that Resident 1 received the necessary care and services for an indwelling catheter, which resulted in complications that included a urinary tract infection. An unannounced visit was made to the facility on December 9, 2010 at 12:00 PM to investigate a complaint regarding medical care neglect of Resident 1. Resident 1 was a 72 year old female admitted to the facility on September 27, 2010, and readmitted on December 1, 2010 following an acute care hospitalization. The resident's initial admission diagnoses included altered level of consciousness, urinary tract infection, muscle weakness, difficulty walking, she had in place a gastrostomy tube, (a tube placed into the stomach to provide a means of feeding the resident) and an indwelling urinary catheter (a tube inserted into the bladder to keep the bladder empty of urine). On December 9, 2010 a review of the resident's initial Admission Nursing Assessment (unsigned) dated September 27, 2010 at 7:00 PM, revealed Resident 1 had no skin breakdown or skin discoloration. The resident was dependent via a gastrostomy tube for nutrition. For mobility, hygiene and grooming needs, the resident required two person total assistance. The bowel and bladder assessment was left blank. Resident 1 was admitted with a urinary catheter in place. A review of the Physician's History and Physical notes dated September 28, 2010 indicated the resident was admitted from the acute care hospital to continue antibiotic therapy and evaluation for physical, occupational and speech therapy rehabilitation services. The physician documented the resident did not have the capacity to understand and make decisions and further documented the resident was unable to talk.A review of the physical therapy and occupational therapy notes dated September 28, 2010 to November 4, 2010, indicated the resident required maximum assistance to perform all ADLs (activities of daily living, such as bathe, dress, and groom, transfer from surfaces to or from bed, chair, wheelchair, walk, toilet use, eat, use speech, language or other functional communication system) and needed maximum assistance with mobility such as turning while in bed, assistance getting in and out of bed.A review of the Activity Assessment Notes dated September 28, 2010 indicated Resident 1 was non-verbal, and did not have the capacity to understand and make needs known. A review of the documentation in the social worker's Weekly Progress Notes dated October 18, 2010 also indicated that, "Resident remains predominantly non-verbal." Review of Resident 1's Braden Scale (a standardized pressure ulcer risk assessment tool to assess a resident's risk upon admission, weekly for the first four weeks after admission, then quarterly, or whenever there is a change in cognition or functional ability) dated September 27, 2010 (done one time only) showed a score of 10, which identified the resident at high risk for the development of pressure ulcers (a total score of 12 or less represents high risk). The correlating risk factors included the following: 1. Inability to perceive pressure 2. Incontinence/moisture 3. Decreased activity level 4. Inability to reposition self 5. Poor nutritional intake 6. Friction and shear complete lifting without sliding against sheets is impossible. Frequently slides down in bed, requiring frequent repositioning with maximum assistance. Pressure ulcers are staged in the following way per the National Pressure Ulcer Advisory Panel: Stage I - A reddened area on the skin that, when pressed, does not turn white Stage II - The epidermis or topmost layer of the skin is broken, creating a shallow open sore. Drainage may or may not be present. Stage III - The break in the skin extends through the dermis (second skin layer) into the subcutaneous and fat tissue. The wound is deeper than in Stage Two. Stage IV - The breakdown extends into the muscle and can extend as far down as the bone. Usually lots of dead tissue and drainage are present. A review of the medical record dated October 11, 2010 in the nurse's progress notes, indicated the resident developed redness to the right buttocks. A physician's telephone order dated October 11, 2010 stipulated sensicare (a protective barrier cream adheres to and helps treat open skin trauma) for redness to right buttock every day and as needed for 14 days from (10/11 to 10/25); the treatment was reordered October 25, 2010 for an additional 14 days from (10/25 to 11/8). A review of the "Treatment Record" (a facility form where nurses signatures are documented to indicate they administered skin care treatments to a specific resident) for the month of October 2010 and November 2010 revealed eight treatments were not administered on the following dates; ( 10/14, 26, 27, 28, 29, 30, 31 and 11/2/2010). No evidence was found in the medical record to indicate the pressure ulcer was monitored and reevaluated for treatment response and or final outcome.A review of the Nurse's Progress Notes dated October 26, 2010, indicated a second pressure ulcer was identified and described as, "Open area to coccyx," which measured "2 cm x 2 cm (centimeter) with redness to surrounding areas."A review of the physician's telephone order dated October 26, 2010 stipulated the following, "Apply hydrocolloid to coccyx every three days, and as needed for 14 days then re-evaluate. Monitor for signs/symptoms of infection." A clarification order was written on October 28, 2010; the following was noted, "Cleanse open area on coccyx with normal saline, pat dry, apply a duo-derm patch every three days and as needed for 14 days then reevaluate." A review of the Treatment Record dated October 2010 and November 2010, showed no documented evidence that the prescribed treatments were done on the following dates: November 2010, "11/1, 11/2, 11/3, and 11/4, 2010." In addition, the duo-derm dressing was not written on the treatment record, even though it was part of the prescribed treatment order. A review of the Wound/Skin sheets (a facility form where nurses document weekly skin assessment and treatment data specific to a resident) dated October 28, 2010, November 3, 4, and 10, 2010, indicated that the pressure ulcer to the coccyx advanced from a Stage II which measured 1.5 cm x 1.0 cm, to a Stage III, which measured 3.0 cm x 4.0 cm. ( in fourteen days) on November 10, 2010.Further review of the Wound/Skin sheets dated October 2010 and November 2010 identified a third pressure ulcer to the left lower buttocks stage II, with the following measurements: October 28, 2010: 0.5 cm x 0.5 cm. November 4, 2010: 3.5 cm x 3.5 cm. November 11, 2010: 3.5 cm x 5.0 cm. A review of the wound care and assessment sheets did not show documentation that included whether the physician and or dietary department were notified of the resident's wound status. A physician's treatment order for the third pressure ulcer to the left lower buttocks was not obtained until November 8, 2010 at 10:00 AM. (12 days after initial identification). There was no documented evidence that the wounds were monitored for signs and symptoms of infection as prescribed on October 26, 2010 and for the following dates: November 1, 2010 through November 18, 2010 (18 days). A review of the Nurses Weekly Progress Notes dated October 1, 2010 through November 5, 2010, under the heading, "Head to toe body check was performed," showed inconsistent and blank areas on the document. The body diagram was blank; this indicated the patient had no skin issues. On December 9, 2010 at 12:40 PM, an observation was made of Resident 1's coccyx pressure ulcer; also present were the licensed nurse, the Director of Nurses (DON) and the Director of Staff Development (DSD nurse). The licensed nurse and the DSD repositioned the resident onto her side and removed the dressing. This revealed a large deep open wound to the coccyx area, the wound bed tissue appeared whitish-gray in color, and the surrounding tissue appeared pale/pink. The licensed nurse was asked for clarification concerning the discrepancies found in the record of assessments which documented the resident had no skin breakdown, and the observation of a large pressure ulcer on Resident 1's coccyx. The licensed nurse had no explanation for the discrepancy and acknowledged that the resident's pressure ulcer was not documented in the nurse's skin assessment notes.A review of the care plan titled "Potential for Impaired Skin Integrity" dated September 28, 2010, included the following: "Reposition per turn schedule." However the care plan did not indicate what the schedule was or where it could be found."Preventive measures per protocol." Preventive measures were not defined and documented. "Skin check every week." A review of the "Licensed Nurse's Weekly Progress Notes," revealed this was not done; the resident's large pressure ulcer was not identified or documented in the record.During an interview on December 9, 2010 at 1:00 PM, with the licensed charge nurse, she was asked about the resident's turn schedule and how she ensured the schedule was followed by the direct care givers (CNAs) as stipulated in the care plan. She stated, "I do rounds to make sure my CNAs turn the resident every two hours, they (CNAs) know what is expected." During on-going observations of Resident 1 on December 9, 2010, at 1:00 PM, 3:40 PM, 4:30 PM, and 5:15 PM, the resident was observed to lie continuously on her right side for 5.20 hours. She appeared thin and frail and did not respond when called by name. The nursing staff was not observed in the resident's room to monitor or reposition her. The licensed charge nurse was informed of the observations and findings and acknowledged the resident had not been turned.A review of the physician's telephone order dated October 27, 2010, stipulated a "Low air loss mattress due to open area to coccyx." (an assistive device used to prevent or alleviate pressure ulcers in resident's who are unable to move on their own. To achieve correct results in prevention/treatment, the resident must be moved periodically, to redistribute pressure).On December 16, 2010 at 11:45 AM, accompanied by the licensed nurse and the DSD, an observation was made of Resident 1 in bed. The air pressure dial for the mattress was set at 150 pounds, although the Weight Record dated December 9, 2010 indicated the resident weighed 97.5 pounds (a 52.5 pound discrepancy); the mattress felt hard to the touch. The LVN was asked why the mattress felt hard and for clarification on the appropriate use of the air mattress for Resident 1's specific needs, she stated, "We usually just set it (mattress air pressure) at 150 pounds, the mattress will alarm if the air is too low." However the DSD acknowledged the air pressure was too high and not appropriate for the resident's needs.A review of the physician's telephone order dated November 18, 2010 revealed the resident was transferred to the acute care hospital related to respiratory distress.A review of the acute care hospital record which included (nine) photographs of the resident's pressure ulcers and the wound care consult notes dated November 19, 2010 at 10:40 AM, indicated Resident 1 had an "unstageable pressure ulcer of the coccyx (full thickness tissue loss in which the base of the ulcer is covered by slough or eschar in the wound bed) which measured 7.0 cm (centimeters) in diameter. Yellow slough (dead skin) noted. The skin surrounding the ulcer was "purple DTI" (indicative of deep tissue injury). The documentation also indicated a Stage II ulcer (a partial thickness loss of dermis presents as a shallow open ulcer with red/pink wound bed and or slough) right next to the coccyx with a pink wound bed and minimal sero-sanguineous (thin watery blood) drainage and no odor." A review of the facility's policy and procedure pertaining to "Skin integrity Program and Treatment Guideline" Included the following: Policy: "It is the policy of the facility to provide appropriate assessment, care and services to (1) promote the prevention of pressure sore development, (2) promote the healing of pressure sores that are present, and (3) prevent the development of additional pressure sores." Procedure: "Complete full body skin assessment within first 2 hours of admission if possible." "Complete Pressure Ulcer Risk Assessment (Braden Scale) on day of admission and weekly for first 4 weeks, then quarterly and with significant change." "If the resident is assessed to be at risk for pressure sores, develop and implement a preventive care plan that includes individualized interventions for identified risk factors." "Licensed nurse will complete weekly head to toe skin assessment." "Nurse will document change of condition in the medical record." "Nurse will communicate change of condition on the 24-hour report (notify treatment nurse and RD)." "Nurse will assess and manage pain related to skin impairment." "Nurses will visually monitor affected area(s) daily for complications." "Registered Nurse will assess weekly, verify pressure sore staging and measurements and sign weekly progress report." "Skin/weight committee will evaluate pressure sore progress weekly and recommend interventions as needed." "Nurse will reevaluate the effectiveness of treatment orders and notify MD for treatment order change if there has been no improvement in 14 days." "Wound specialist will consult and recommend wound treatments as needed." Further review of the resident's admission documentation dated September 27, 2010, showed the resident had an indwelling urinary catheter in place at the time of admission. In addition, the Nursing Admission Assessment dated September 27, 2010 showed an incomplete comprehensive assessment, including a blank sheet for the bowel and bladder assessment.Review of the Licensed Nurse's Weekly Progress Notes dated October 1, 8, 22, 29, 2010 and November 5, 2010, revealed recurrent documentation which indicated the resident did not have any symptoms of UTI (urinary tract infection). Review of the clinical record found no plan of care was developed to address the resident's indwelling urinary catheter care needs and risks associated with a history of UTI.Review of the Licensed Nurses Progress notes dated October 20, 2010 revealed documentation which indicated the resident's urinary catheter was changed due to "leaking of cloudy yellow urine." However, there was no documented evidence in the clinical record to indicate the physician was notified of the change in urinary status.Further review of the Nurse's Weekly Progress note dated October 22, 2010 (two days later) failed to document the change in condition of the resident's urinary status, and or document the date the new catheter was inserted. A review of the physician's order dated October 31, 2010 at 1:00 PM included an order for a urine analysis for culture and sensitivity to be done on November 1, 2010 in the morning, due to "milky urine." The order also included the following; "Foley Cath 20 fr/5cc (diameter size of catheter tube and inflation size of water filled balloon to keep tube in place within the bladder). Change every 30 days and as needed for plugging or leaking. Foley Cath. care daily." Review of the laboratory results of the (urine) specimen dated November 1, 2010, showed the resident had a positive UTI (urinary tract infection). However, according to the documentation reviewed, the physician was not notified until three days later, on November 4, 2010 at 9:00 AM. At that time, a physician's telephone order was obtained for "Ciprofloxacin 500 mg. (milligram) by mouth twice a day for 5 days for UTI." A review of the resident's treatment records dated October 2010 and November 2010, failed to show documented evidence of catheter care provided to the resident. On December 9, 2010 at approximately 3:30 PM, the licensed nurse was informed that a review of the record did not show catheter care was provided to Resident 1; she stated that the treatment nurse was responsible for catheter care and acknowledged that there was no documented evidence catheter care was done for the resident. Review of the Licensed Nurses Progress Notes dated from admission on September 27, 2010 to November 18, 2010, found no documentation that catheter care was done for Resident 1. The recurrent documentation indicated "Foley catheter patent." (opened and unblocked). Two entries were documented; the first on October 30, 2010 at 11:30 AM, which indicated that the catheter was "Patent and intact, without odor and or sediment, (a deposit of material that settles at the bottom of urine) no problems noted." The second entry on October 31, 2010 at 12:30 PM indicated the catheter was leaking and the urine had a milky white appearance and a strong odor was noted. Review of the facility's policy and procedure entitled "Catheter Care" dated 6/1/09, included the following: "Residents with indwelling urinary catheters will receive the necessary care and treatment to promote dignity and comfort and to reduce the risk of developing complications from indwelling catheter use." "Catheter care may be performed as a nursing intervention with or without a physician's order; however, it is recommended to have a physician's order to facilitate documentation in the treatment record." "Catheter care instructions should be included in the care plan for all residents with indwelling catheters." "A trained nurse assistant or licensed nurse may perform catheter care." "The licensed nurse will assure and document that routine catheter care is provided as directed by the care plan." "Routine catheter care includes: Observing for signs of irritation or infection. Cleansing the catheter tubing and the urethral meatus (the anatomical structure that drains urine from the bladder) as directed by the care plan and as needed to promote a sense of cleanliness, dignity, and personal hygiene." "Report immediately any unusual observations that may indicate complications or infection, including change in amount or appearance of urine output, increased or abnormal discharge, unpleasant odor, redness, irritation, or discomfort." Review of the acute care hospital records included a laboratory report dated November 18, 2010, which revealed the resident had a urinary tract infection. In addition the history and physical examination report dated November 18, 2010, written by the physician, included the following: "Respiratory failure secondary to sepsis (infection), hypotension (low blood pressure) secondary to sepsis and dehydration." These facility failures had a direct relationship to the health, safety, or security of long-term care facility patients or residents. |
| 240000650 |
Terracina Post Acute |
240010561 |
B |
25-Mar-14 |
1FY611 |
5334 |
REGULATION VIOLATION: Title 22 72527 Patients' Rights (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedure which include these rights and shall make a copy of these 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. Based on observation, interview and record review, the facility failed to ensure that Patient 1was free from physical abuse when Certified Nurse Aide 1 (CNA 1) slapped Patient 1 in the face. This action resulted in Patient 1 to sustain contusions (when the blood vessels under the skin are broken, and blood collects, usually caused by a blunt trauma, causing pain and discoloration) to the right side of her face. A record review, conducted on June 25, 2013, revealed that Patient 1 was admitted to the facility on August 7, 2012 with diagnoses which included dementia and Alzheimer?s (a disease in which the memory and thinking abilities are affected. The disease is progressive, resulting in the inability to care for self and eventual death), psychosis (a loss of contact with reality), and insomnia (unable to sleep). A review of a facility document titled, "Patient Change of Condition Notification and Documentation", dated June 20, 2013, at 3:00 AM, signed by Licensed Vocational Nurse 1 (LVN 1) revealed, "Discoloration under right eye, as stated by two NOC (shift from 11:00 PM to 7:00 AM) CNAs. The area has become bigger and the discoloration has become darker with mild swelling..."Review of LVN 1's progress note, dated June 21, 2013, at 7:30 AM, revealed, "Entry for June 20, 2013, at 3:00 AM clarification...At 2:00 AM (on June 20, 2013) two NOC CNA's reported (name of Patient 1) had swelling and discoloration to her right eye." A review of a facility document dated June 20, 2013, and titled, "Interdisciplinary Team Conference Record", revealed, "On June 20, 2013, Resident noted to have area of discoloration and swelling to below right eye, also upon reassessment Resident had also area of discoloration to chin area on right side as well...Resident does not recall event..." During an interview with the administrator, on June 25, 2013, at 1:30 PM, she stated that on the morning of June 20, 2013 at 2:00 AM, Patient 1 had insomnia and was sitting in the hallway in a wheelchair. The administrator further stated that CNA 1 was responsible for monitoring Patient 1 in the hallway, from 2:00 AM to 2:30 AM and that on the morning of June 20, 2013, around 2:30 AM to 3:00 AM, facility staff discovered that Patient 1 had redness to the right side of her face.During continued interview with the administrator she stated that CNA 1 had verbalized to her that during the time she was monitoring Patient 1, on June 20, 2013, from 2:00 AM to 2:30 AM, she slapped Patient 1 on the right side of the face with the back of her hand.During an interview with CNA 1, on June 25, 2013, at 3:20 PM, she stated that on the morning of June 20, 2013, from 2:00 PM to 2:30 PM, she was responsible for monitoring Patient 1. She stated that Patient 1 was awake in the hallway, and sitting in a wheelchair. CNA 1 stated that Patient 1 had a behavior of sliding down in the wheelchair and required frequent repositioning. CNA 1 stated that Patient 1 kept sliding down in the wheelchair and that she had to continuously reposition Patient 1. CNA 1 stated that initially she used her right foot to tap Patient 1 on the lower part of her right leg and told her to stop sliding down. CNA 1 also stated, "I felt overwhelmed and slapped (Patient 1's) face with the back of my hand."A review of CNA 1?s signed written statement, dated June 20, 2013, revealed, "Last night on the night of 6/19/13 (June 19, 2013, the date that CNA 1 began her NOC shift) out of frustration I did something unspeakable, I abused a patient."During an observation on June 25, 2013, at 3:50 PM (five days after CNA 1 had admitted to and documented that she slapped Patient 1) revealed that Patient 1 was in the wheelchair, sitting in the day room. The right side of Patient 1?s face was observed to have dark purple, red, and yellow discoloration covering almost the entire right side of the face. The discoloration was under and around the right eye, on the right cheek bone, and on the right side of the mouth and chin.A review of the facility policy titled, "Abuse Prevention and Elder Justice Program, Version: 02.2013", revealed, "This facility recognizes that each resident has the right to be free from all forms of abuse...all forms of abuse are strictly prohibited by the facility. Abuse means the willful infliction of injury...physical abuse includes hitting, slapping, pinching, and kicking."During an interview with the administrator, on June 25, 2013, at 1:30 PM, she stated that physical abuse was inflicted upon Patient 1, when CNA 1 slapped Patient 1 on the right side of the face, which resulted in a contusion to Patient 1?s right eye, cheek and chin. Therefore the facility failed to ensure that Patient 1 was free from physical abuse. This violation had a direct relationship to the health, safety, or security of the patient. |
| 240000650 |
Terracina Post Acute |
240013350 |
A |
19-Jul-17 |
YFWW11 |
7484 |
A Citation - Complaint - CA00537599
Regulation Violation:
Title XXII 72313 (a) (2) Nursing Service- Administration of medication and treatment.
(a) Medication and treatments shall be administered as follows:
(2) Medications and treatments shall be administered as prescribed.
FINDINGS:
The facility failed to ensure that all tests and medications ordered at the time of admission were transcribed and administered to one of three sampled patients (Patient 1), when insulin (Insulin Aspart- controls blood sugar) and finger stick blood sugars were missed for a total of 10 days.
This failure resulted in Patient 1 experiencing hyperglycemic hyperosmotic non- ketotic syndrome (HHNS, a complication of high blood sugar state causing severe dehydration, increases in osmolality (relative concentration of solute) and a high risk of complications, coma and death. It is diagnosed with blood tests), requiring an admission to the general acute care hospital (GACH 2).
During a review of Patient 1's electronic clinical record (e-record) the "Face sheet" (a document which provides the demographic data of the patient) indicated Patient 1, was a 57 year old female, admitted to the facility on XXXXXXX 2017, at 7:45 PM, from a General Acute Care Hospital (GACH 1), with diagnoses which included: acute respiratory failure (a condition in which the level of oxygen in the blood becomes dangerously low or the level of carbon dioxide becomes dangerously high), metabolic encephalopathy (brain disease caused by abnormalities of the water, electrolytes, vitamins, and other chemicals that adversely affect brain functions) and diabetes mellitus type 2 (DM 2-is a long term metabolic disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) and had a gastrostomy tube (GT- a tube inserted through the abdomen that delivers nutrition directly to the stomach).
A review of the discharge orders from the transferring facility (GACH 1) dated XXXXXXX 2017, for Patient 1, included, "Insulin Aspart, subcutaneous (under the skin) injection, units sliding scale (insulin dosed based on finger stick blood sugar readings), if BS (blood sugar) < (less than) 50 milligram per deciliter (mg/dl) (a unit of measurement), critical value, notify MD (physician). If BS < 61, see D50 (50% Dextrose solution given to raise blood sugar) order. If BS 150 to 200, give 3 units [insulin]. If BS 201 to 250, give 5 units [insulin]. If BS 251 to 300, give 7 units [insulin]. If BS 301 to 350, give 9 units [insulin]. If BS 351 to 400, give 11 units [insulin]. If BS > (greater than) 400, Notify MD. If BS >450, critical value Notify MD. First dose (order initiated) 4/6/17 (April 6, 2017) 0600 (6 AM), Q6H (every six hours), last dose 5/17/17 (May 17, 2017) 7:08 AM."
A review of Patient 1's "Order Summary Sheet," dated May 17, 2017, did not include the transfer order to continue the finger stick blood sugars with the sliding scale dose of insulin, as prescribed in the discharge orders from the transferring facility (GACH 1).
During an interview with the Registered Dietician (RD) on June 13, 2017, at 2:10 PM, she stated that she was not informed about Patient 1's diabetic diagnosis.
During an interview with a Registered Nurse (RN 1) on June 13, 2017 at 3:08 PM, she reviewed the e-record and was unable to find documentation of the medication verification with the physician upon admission for Patient 1. RN 1 described the admission order verification process as follows: when a new admission comes it is the licensed nurses' responsibility to call the physician and verify the orders and document the verification in the residents' e-record.
An interview was conducted on June 13, 2017 at 3:14 PM, with the Licensed Vocational Nurse (LVN 1) who had entered the transfer orders into Patient 1's electronic clinical record. LVN 1 stated that she verified with Patient 1's physician regarding the admission orders via her personal cell phone. LVN 1 was unable to show the evidence of communication with the physician stating, "Those texts were accidently deleted from my phone." LVN 1 reviewed Patient 1's e-record and was unable to find any documentation of medication verification, or the order for the finger stick blood sugars nor insulin as ordered on the discharge transfer form from the GACH 1.
A review of Patient 1's "Physician Progress Notes" written by Physician 2, dated May 19, 2017, indicated that Patient 1 had a history of DM 2 and the facility staff were to "...continue present discharge orders" [from GACH 1].
During a telephone interview with Physician 2, on June 16, 2017 at 11:55 AM, he stated that he did not receive any call or text regarding Patient 1's admission orders. He further stated that during his onsite visit with Patient 1, on May 19, 2017, he reviewed the discharge orders from the previous facility [GACH 1] for Patient 1 and recommended to continue the orders.
During an interview with the Director of Nurses (DON), on June 13, 2017 at 2:22 PM, he stated that when a new admission comes into the facility, more than one licensed staff and the physician review the orders. He was unable to explain how this medication order had been missed.
A review of Patient 1's Medication Administration Record (MAR) for the month of May 2017, indicated that Patient 1 did not have the finger stick blood sugar checks nor insulin orders reflected on the MAR.
A review of Patient 1's clinical record titled, "SBAR(Situation Background Assessment Recommendations)/ Acute Care Transfer", dated May 27, 2017, indicated that Patient 1 required a transfer to the acute care hospital (GACH 2) due to shortness of breath.
A review of the admission assessment from the general acute care hospital (GACH 2) where Patient 1 was transferred dated XXXXXXX 2017, indicated that Patient 1 was admitted for "Hyperglycemia" (high blood sugar). Further review of the clinical record indicated that Patient 1 was in a state of severe dehydration due to HHNS. Patient 1 was being treated in GACH 2 with a continuous insulin drip (intravenous administration of insulin) for hyperglycemia.
A review of the of the clinical laboratory results for Patient 1, from GACH 2, dated May 27, 2017, indicated that the blood sugar level was 949 mg/dl where the normal range was 70-110 mg/dl (unit of measure).
A review of the skilled nursing facility's policy and procedure titled, "Reconciliation of Medication on Admission," revised December 2012, indicated: "The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission." The policy further indicated that licensed nurses were required to communicate with the physician for medication reconciliation and document that in the residents' medical record on admission.
Because the facility failed to ensure that all tests and medications ordered at the time of admission were transcribed and administered as per physician orders, Patient 1 experienced a change of condition requiring an emergency admission to the hospital.
These facility failures presented either (1) imminent danger that death or serious harm to the patients of the long-term health care facility would result therefrom; or (2) Substantial probability their death or serious physical harm to patients in the long-term health care facility would result therefrom. |
| 250001635 |
THE JOHN FURBEE HOUSE |
250009186 |
B |
29-Mar-12 |
C34I11 |
3692 |
Citation ? The John Furbee House CA00248315?B? Citation W&I Code4502 ? Rights of persons with DEVELOPMENTAL DISABILITIES.Persons with developmental disabilities have the same rights and responsibilities guaranteed all other individuals by Federal all other individuals by Federal Constitution and Laws and the Constitution and Laws 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 A was free from harm, including the use of physical restraint that caused injury to the client?s wrists, due to a staff person physically restraining Client A.On November 15, 2010, during the investigation of a reported event, the following was noted: Client A, a 27 year old female, was admitted to the facility on October 7, 1999, with the diagnoses of; 1. Profound MR (mental retardation), 2. Seizure disorder, and 3. History of Retts Syndrome (low blood pressure and slow heart beat).A review of the Confidential Investigation report, written on November 11, 2010, showed that on November 4, 2010, the QMRP (Qualified Mental Retardation Professional) had documented, ?I received a call from ?Name? (DCS 1) stating that she had observed ?Name? (DCS 2), an on-call staff, using inappropriate interventions with Client ?Name? (Client A) on 10/31/10 during that evening.?On October 30 &31st of 2010, DCS 2 was called to work from 4 p.m., specifically to provide close observation of Client A. Client A had been more agitated lately and was having drug changes for the behaviors of agitation, running around, banging her head on the walls, screaming and grabbing other clients food. On November 15, 2010 at 5:58 p.m., an interview was conducted with DCS 1. DCS 1 stated, ?It was dinner time and ?Name? (Client A) was acting up at the table, trying to stand on the table or grab other clients? food, and then ?Name? (Client A) ran outside to the back patio. DCS 2 ran outside to the back patio, grabbed ?Name? (Client A) by the wrist and dragged her into the house. ?Name? (Client A) sat down on the floor and ?Name? (DCS 2) leaned over and then grabbed both wrists on Client A. In grabbing both wrists, ?Name? (DCS 2) had the hands of ?Name?s? (Client A) crossed over her chest and was yelling, ?I can?t handle her, I can?t handle her.? DCS 1 stated, ?I told ?Name (DCS 2) that I would take care of ?Name? (Client A) and that ?Name? (DCS 2) could watch over my two clients.? DCS 1 stated, ?I noticed pink red areas on both wrists where ?Name? (DCS 2?) had been holding her (wrists).? On November 15, 2010 at 5:10 p.m., Client A was observed with scabbed scratch marks to the right inner wrist.The personnel file of DCS 2 was reviewed on November 24, 2010. The file indicated that DCS 2 was a re-hire on September 13, 2010. DCS 2 signed and acknowledged trainings in Adult/Elder Abuse Mandated Reporting, Child Abuse Reporting, and the Department of Justice requirements. Therefore, the facility failed to ensure Client A was free from harm, including physical restraint that caused injury to the client?s wrists from being physically restrained by DCS 2.The above violations jointly, separately, or in any combination had a direct or immediate relation to Client A?s health, safety, or security. |
| 250000260 |
THE SPRINGS AT THE CARLOTTA |
250010072 |
B |
04-Sep-13 |
YP6811 |
7751 |
72315 (b) (b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind. The following information was obtained during an entity reported incident investigation. The facility reported that an occupational therapist had been terminated for verbal confrontations with patients. On September 22, 2008, an onsite visit was conducted at the facility to investigate an entity reported incident. The facility failed to: 1. Ensure that Patient 1 was treated with dignity and respect and free from verbal abuse from an occupational therapist (OT). The OT was heard to speak to the patient in a manner that the patient's family member described as "harsh, dictatorial and uncaring."2. Ensure that Patient 1 was treated with consideration, respect and full recognition of dignity and individuality by making the patient cry when the OT insisted that the patient complete her OT treatment after she complained of chest pain. 3. Ensure its standard of zero tolerance of patient abuse was followed by all facility team members. Patient 1 was an 81 year old female who had been admitted to the facility with diagnoses that included acute chronic obstructive pulmonary disease (COPD- a disease characterized by shortness of breath) and acute myocardial infarction (heart attack). The patient had been admitted to the facility from the acute care hospital for continued medical and nursing care and for physical and occupational therapy to assist in regaining her strength and ability to care for herself. An interview was conducted with the facility's Director of Nurses (DON) at 8:55 a.m. The DON stated that twelve therapists, provided by an outside provider, started working at the facility on August 25, 2008.At 9 a.m. on September 22, 2008, the DON stated that on September 10, 2008, the Social Services Coordinator (SSC) came into his office and told him that Patient 1's daughter had telephoned her to ask what was going on because the OT had made her mother, Patient 1, cry during her therapy treatment. The DON stated that he called Patient 1's daughter right away when he got the report from the SSC. The DON presented his written statement, completed on September 10, 2008, at 9 a.m. on September 22, 2008. The DON wrote that Patient 1's daughter was "upset and angry with our OT." Issues discussed in the written document with Patient 1's daughter were discharge planning and treatment of her mother during therapy sessions.The DON's written statement went on to indicate that Patient 1's daughter told the DON that she had been working closely with the discharge planner and the OT came in and contradicted everything the discharge planner had told her mother about discharge. When Patient 1 attempted to ask questions, the OT cut her off and told her what was going to happen. The daughter described the conversation to the DON as, "harsh, dictatorial, direct and uncaring manner," Patient 1's daughter told the DON that she was ready to "pull her mother out of the community (facility) if her mother had to continue with (Name) as treating occupational therapist." In addition to the incident about the patient's discharge, the daughter told the DON that the OT came up to her mother after her PT session and told her it was time for her OT. Patient 1 told the OT that she was too tired and needed to rest. The OT told her she was going to have her OT and that she would participate. The patient again told the OT that she was too weak and tired, and that she was having chest pain. The DON stated that the OT did not tell the nursing staff about Patient 1's complaint of chest pain. After the DON spoke to Patient 1's daughter, he started an investigation of the OT's behavior right away. The SSC was interviewed on September 22, 2008 at 3:25 p.m. She stated that Patient 1's daughter had called her to find out what was going on because her mother had just called her a work and was crying. Patient 1's daughter told the SSC that the OT had told her mother that her discharge date had been moved up a week. The SSC said that she also acted in the role of discharge planner and had been working with Patient 1's daughter on a long term stay. The daughter told the SSC that this information needed to come from her or the SSC, but not from the OT.At 4:30 p.m. on September 22, 2008, Patient 1's record was reviewed. The Minimum Data Set (MDS - an assessment tool) indicated the patient had no long or short term memory deficits and was independent in her daily decision making skills. The MDS indicated Patient 1 had no problems with making herself understood or understanding others. At 10 a.m. on September 23, 2008, a telephone conversation was conducted with Patient 1's daughter. She told the surveyor that one day when she was visiting her mother, the OT told her (the daughter) to bring her mom's portable oxygen because he was tired of pulling the oxygen behind her mother. The daughter explained that her mother had "COPD" and had recently suffered a major heart attack.On another visit, the daughter said that the OT had insisted that her mother use a certain walker, but she didn't want to use it. The patient's daughter asked the OT why her mother had to use "that one." He told her that, "He had been in the business for 20 years and he knew best." Patient 1's daughter said her mother had called her on Wednesday (September 10, 2008) and was very upset and crying. The daughter said, "Mom doesn't get upset and cry easily." The OT told her mother that she was, "maxed out and needed to go home." When the patient asked what he meant, he told her, "That's just the way it is," and didn't explain any further. Patient 1 told her daughter to, "Just ask others. He's (OT's name) mean and he pushes way too hard." On September 24, 2008, at 1:40 p.m., an interview was conducted with Patient 1.She reported that she didn't like the walker she was given to use by the OT. He also told her that he was going to take her oxygen away because he didn't want to carry it as she walked. Patient 1 said that the OT always bragged a lot and thought that his job had gone to his head. She said the OT said "a lot of mean things to me," but said she could not remember exactly what he said.On October 29, 2008, the facility's corporate policy and procedure (p/p), Skilled Nursing Abuse Investigative Protocols dated August 25, 2006, was requested and reviewed at 3:45 p.m. The p/p indicated that, "(Name of Corporation) Senior Living Services had adopted a zero tolerance of patient abuse. The (Name of Corporation) Senior Living Services will not tolerate any form of patient abuse." Under item D, the p/p further defines verbal or mental abuse as: "Use of oral, written or gestured language that deliberately includes disparaging or derogatory terms within hearing distance of patients or family members, regardless of age, ability to comprehend or disability." The p/p further indicates, "Threats of physical or emotional pain are also considered verbal abuse." The facility's failure to monitor and ensure the OT's lack of treating Patient 1 with respect and dignity put all the patients who received occupational therapy services at risk for potential loss of respect and dignity. The facility failed to: 1. Ensure that the OT spoke to Patient 1 in a respectful and dignified manner that was not harsh, dictatorial, and uncaring.2. Ensure that Patient 1 was treated with respect and dignity and not made to cry by what the OT said to her. 3. Ensure that it adhered to its standard of zero tolerance for verbal or mental abuse was followed by all providers of care in the facility. The above violations had a direct relationship to the health, safety, security of patients. |
| 250000260 |
THE SPRINGS AT THE CARLOTTA |
250010083 |
B |
04-Sep-13 |
YP6811 |
8229 |
72315(b) 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. The following information was obtained during an entity reported incident investigation. The facility reported that an occupational therapist had been terminated for verbal confrontations with patients. On September 22, 2008, an onsite visit was conducted at the facility to investigate an entity reported incident. It was determined that the facility failed to: 1. Ensure that an occupational therapist (OT) spoke to Patient 2 in a respectful and dignified manner when he told her that if she didn't like the treatment she was getting, she could go elsewhere; that he was not a puppet; and that the patient would respect him. 2. Ensure that Patient 2 was treated with consideration, respect and full recognition of dignity and individuality when an OT took the patient's personal sling away from her and later dangled it in her face in a taunting way when he returned it to the patient. 3. Ensure its standard of zero tolerance of patient abuse was followed by all facility team members. Patient 2 was an 82 year old female who had been admitted to the facility on August 20, 2008, for aftercare of healing, traumatic fracture of her upper left arm. The patient's Minimum Data Set (MDS) with an assessment reference date of September 9, 2008, indicated that she had no cognitive deficits with her short or long term memory. The MDS further indicated that the patient's speech was clear and she had no problems being understood or understanding others.An interview was conducted with the facility's Director of Nursing (DON) at 8:55 a.m. The DON stated that twelve therapists, under contract to the facility from an outside provider started working at the facility on August 25, 2008. He stated that on September 10, 2008, the facility's Social Services Coordinator (SSC) had come to him and reported that Patient 2 had been refusing her therapy because she did not like the OT and they often disagreed about her sling and therapy treatments. In the interview with the facility's SSC on September, 22, 2008, at 3:25 p.m., she stated Patient 2 told her on Thursday, September 10, 2008, that she didn't like the way the OT talked to her. The SSC further stated she had to attend Patient 2's OT sessions so she would continue the therapy. The SSC said she was present and heard the OT telling Patient 2 that if she didn't like the treatment she (the patient) could go some where else. She said he also told Patient 2 that, "I'm not a puppet, and you're not going to treat me like one. You're going to respect me." The SSC said she told the OT to "knock it off," when they were out of the patient's room. The SSC said she told the OT that he had been inappropriate with Patient 2. The SSC stated that she went to the DON on Thursday (September 11, 2008), and told him what she had heard the OT say to Patient 2.The SSC said, "The OT wanted everybody to know he was in charge."A telephone interview was conducted with Patient 2 on September 25, 2008, at 9:40 a.m. The patient explained that she had a broken shoulder and had been admitted to the facility from the hospital for therapy. Patient 2 stated that the OT had not liked the sling that was being used when she was admitted to the facility and had taken it away. He told her he didn't like it and would give her a different one. Patient 2 stated that he removed it, and took it out of her room. She said she had refused to wear the new one until she got an approval from her doctor, as that was the sling her orthopedic surgeon had told her to wear. Patient 2's record was reviewed on September 22, 2008 at 4 p.m. The review indicated that Patient 2's doctor had written an order on August 20, 2008, for the patient was to wear a sling to her left arm at all times. The patient had been discharged from the hospital with a sling that the OT had taken away from her.Review of the interdisciplinary (ID) progress notes indicated that on August 29, 2008, the patient was walking in the hallway with assistance from OT. The note further indicated that a new "sling" had been ordered and she would receive it the next day. On August 30, 2008, the ID progress notes indicated that Patient 2 was, "Unhappy with brace." On August 31, 2008, at 6 a.m., the ID notes indicated that Patient 2, "Refused to wear Immobilizer." At 3 p.m., a licensed nurse (LN) wrote, "Res. (patient) refuses to wear immobilizer removes it. Made a sling out of short(s). Made aware of risk not wear immobilizer - still refuses to wear it. Therapy spoke (with) res regarding immobilizer res states it makes her arm swell and hurt & (and) she not going to wear it. MD (medical doctor) made aware." On September 1, 2008, a LN wrote, "She refuses to wear immobilizer. Dr (Name) aware. Later on the same date, another LN note indicated, "Called to room by patient. Long discussion regarding immobilizer - conclusion Patient refuses to wear immobilizer. Education given as to why it is necessary. Patient refuses and is using a "home-made" sling. Spoke c therapy PT (physical therapist) & PTA (physical therapy aide) - instructed them to reapply sling that patient refuses immobilizer. Will try to move up ortho (orthopedic) appointment. Patient understands & verbalized possible negative results."In the telephone interview with Patient 2 on September 25, 2008, at 9:40 a.m., she said that she had tied her pajamas together and made her own sling. She said three days later she asked the OT if he had disposed of her sling. He went out of her room and returned with the sling in his hands and dangled it in her face. She stated that it was as if he was telling her "Ha Ha." She said, "I didn't want to go home worse than when I came in." The patient clarified her statement by saying her doctor had wanted her to wear the sling that he had provided to her, the sling that OT had taken away.She further stated, "I have a right to refuse treatment." At the end of the telephone interview on September 25, 2008, at 10 a.m., Patient 2 said, "I hope he didn't hurt anyone." On October 29, 2008, at 3 p.m., the DON stated he was aware that Patient 2 had made a sling out of a shirt of some kind." The DON said that Patient 2 did not want the immobilizer the OT had gotten for her. She wanted to see her doctor before she would wear it. The DON further stated that he had told the OT he couldn't just take the patient's belongings as ("Name of Patient 2") had reported to him. He said he was not aware the OT had dangled the sling that he taken away from the patient in her face. The DON also said that after the patient's MD appointment, her original sling was what the doctor wanted her to wear. On October 29, 2008, the facility's corporate policy and procedure (p/p), Skilled Nursing Abuse Investigative Protocols dated August 25, 2006, was requested and reviewed at 3:45 p.m. The p/p indicated that, "(Name of Corporation) Senior Living Services had adopted a zero tolerance of patient abuse. The (Name of Corporation) Senior Living Services will not tolerate any form of patient abuse." Under item D, the p/p further defines verbal or mental abuse as: "Use of oral, written or gestured language that deliberately includes disparaging or derogatory terms within hearing distance of patients or family members, regardless of age, ability to comprehend or disability." The p/p further indicates, "Threats of physical or emotional pain are also considered verbal abuse." The facility's failure to monitor and ensure the OT's lack of treating Patient 2 with respect and dignity put all the patients who received therapy services at risk for potential loss of respect and dignity. The facility failed to: 1. Ensure that the OT spoke to Patient 2 in a respectful and dignified manner.2. Ensure that Patient 2's personal property was not taken from her without valid reasons and then used it to taunt the patient in a disrespectful manner when it was returned. 3. Ensure that it adhered to its standard of zero tolerance for abuse was by all providers of care in the facility. The above violations had a direct relationship to the health, safety, security of patients. |
| 250000260 |
THE SPRINGS AT THE CARLOTTA |
250010087 |
B |
04-Sep-13 |
YP6811 |
6626 |
HSC 1418.91 (a) 1418.91 Reports of incidents of alleged abuse or suspected abuse of residents(a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident to the department immediately, or within 24 hours.The following information was obtained during an entity reported investigation. The facility reported that a contracted occupational therapist (OT) had been terminated for verbal confrontations with patients eight days after the facility had been made aware of the incidents. On September 22, 2008, an unannounced visit was conducted at the facility to investigate an entity reported incident that was received at the Riverside District Office of the California Department of Public Health on September 19, 2008. The facility failed to: 1. To make a report to the Department within 24 hours of verbal abuse allegations. The facility did not report the abuse allegations for eight days after two patients/patient family member complaints were made to the facility. 2. Follow the facility's policy and procedure to report all suspected incidents of abuse to the Department within 24 hours of the incident. At 8:35 a.m. on September 22, 2008, an unannounced visit was conducted at the facility to investigate a facility-reported incident that was received at the Riverside District Office on September 19, 2008. The event involved a report that a therapy staff, under contract to the facility, had been terminated on September 11, 2008, due to verbal confrontations with two patients. At 8:55 a.m. an interview was conducted with the facility's Director of Nursing (DON). The DON stated that twelve therapists provided by an outside provider, started working at the facility on August 25, 2008.He said that he became aware that the occupational therapist (OT), named as therapy manager by the contracted company, had been verbally abusive towards three patients and to the therapy staff in front of one other patient. The DON said the facility's Social Services Coordinator (SSC) brought the two incidents of verbal abuse to his attention on September 10, 2008, after she had witnessed the OT being verbally inappropriate to one patient, Patient 2, and later when she received a telephone call from another patient's daughter, Patient 1. The daughter told the SSC that the OT had spoken to her mother in a, "Harsh, dictatorial and uncaring manner," and made her mother cry.At 9 a.m. on September 22, 2008, the DON had stated that the facility's administrator had been on vacation on September 10, 2008. He said that he had assumed administrative duties during the absence of the administrator. He further said that he started his investigation into the allegations of verbal abuse as soon as he had been made aware of them on Wednesday, September 10, 2008. He said he telephoned Patient 1's daughter as soon as the allegation had been brought to his attention. After he telephoned Patient 1's daughter, the DON said he continued his investigation into the allegations of verbal abuse. He said that he requested the personnel file of the OT for review. He said he didn't know the facility had not been provided with personnel information listed in the facility's contract with the provider until he reviewed the OT's personnel file on September 10, 2008. The DON stated that his review revealed that the OT's personnel file had no background checks or appropriate licensure and/or certification information in it. He said upon that discovery, he requested all of the contract therapy personnel files. None of the files had any background or reference checks, verification of licensure and/or certification information. He said that the files had no reports of health and TB screening in them. He said that he telephoned the contracted therapy provider in Arizona right away on September 10, 2008, and requested the information that had been required in the facility's contract with the provider to be sent to the facility right away.The DON said he telephoned the provider company again on September 11, 2008 and told the personnel manager that he had not received the background and reference checks along with current licensure and health screenings for the contracted employees as requested on the day before, September 10, 2008. He said that he was assured that all background and reference checks, licensure/certifications, and health screenings had been done and were in order.The DON said he decided that the OT should not be providing care to the facility's patients if the OT was verbally abusing them so he spoke to the OT with the SSC present in his office on September 11, 2008. The DON said the conversation became argumentative, and after speaking with the provider company personnel manager again, he decided that the OT would be terminated. The DON said the OT became "volatile" and "irate," and left the building.At 9:20 a.m. on September 22, 2008, the DON stated that he called the Riverside County Sheriff on Monday, September 15, 2008, and made a police report regarding the verbal abuse and the OT's behavior towards him on September 11, 2008. Two sheriff deputies came to the facility and spoke with the DON and the therapy staff on Tuesday, September16, 2008. The deputies took statements from all the contract therapy staff and the DON. On September 26, 2008, at 10 a.m., the DON presented a copy of the corporate policy and procedure, "Reporting Abuse, Neglect, or Financial Exploitation." Item 3 in the policy's process indicated, "Once the safety and well-being of the patient is established, the executive director, or administrative team member on duty:" shall "Report all information regarding the suspicion of the abuse, neglect, or exploitation to the local reporting agency within 24 hours of the incident. The DON stated he did not remember to contact the Department for a week after the incidents of verbal abuse had been reported to him. He said he had been the one responsible for not reporting the incidents to the Department within 24 hours as written in the facility's policy and procedure and as mandated in the Health and Safety Code. The facility failed to: 1. To make a report to the Department within 24 hours of verbal abuse allegations. The facility did not report the abuse allegations for eight days after two patients/patient family member complaints were made to the facility. 2. Follow the facility's policy and procedure to report all suspected incidents of abuse to the Department within 24 hours of the incident. The above violations had direct or immediate relationship to the health, safety, or security of patients. |
| 250001635 |
THE JOHN FURBEE HOUSE |
250010379 |
B |
16-Jan-14 |
YJK011 |
5957 |
?B? Citation W&I Code 4502 ? 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 State of California. No otherwise qualified person by reason of having a development disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect. The facility failed to ensure Client A was free from unnecessary restraint when Staff 5 blocked Client A?s room exit door opening with the dining table and a chair. This prevented the client from leaving his bedroom at will. An unannounced visit was conducted at the facility on April 2, 2010, to investigate an entity reported complaint regarding an incident of alleged patient abuse and neglect. Client A, a 22 year old male, was admitted to the facility on June 18, 2007, with diagnoses that included: 1. Charge Syndrome, (an extremely complex syndrome, involving extensive medical and physical difficulties) 2. Vision impairment, and hearing loss/deafness 3. Severe intellectual disability4. Seizure disorder, and 5. Autism (preoccupation with inner thoughts, daydreams, delusions, and fantasies). Review of Client A?s behavioral objectives indicated that Client A had behaviors that included biting, sleeplessness, and grabbing staff or peers. On April 2, 2010, at 12:05 p.m., an interview was conducted with the Qualified Intellectual Developmental Professional (QIDP). The QIDP stated that Direct Care Staff (DCS) 1 reported on March 25, 2010, that DCS 5 told DCS 1 that Client A would grab her (DCS 5) during the night, and so DCS 5 would put the dining room table in front of Client A?s door opening to keep him from coming out. On April 2, 2010, at 12:10 p.m., Client A?s room door opening was measured at 41 inches in width, and the dining room table was measured at 48 inches in length by 48 inches in width. A signed, written statement by DCS 1 on March 25, 2010, indicated, ?I was working with the other Noc (night) person (DCS 5) she told me that during her Noc shift when she was asleep, Client A attacked (grabbed) her 3 times so now she puts the dining room table in front of his door.? On March 26, 2010, DCS 1 added to her written statement, ?When she made the comment about the table being in front of the door I wasn?t sure if she was serious.?A signed, written statement by the facility manager (FM) on March 25, 2010, indicated, ?(DCS 1?s name) informed me that (DCS 5?s name) had told her that at night she puts the dining room table in front of Client A?s bedroom door so he cannot come out during the night.? On March 27, 2010, the FM added to her written statement, ?When interviewed by (QIDP?s name) today, I stated that on the 25th of March on P.M. shift before I left that there was a towel under (Client A?s name) bedroom door. I believe because of light shining in room from dining room.?A signed, written statement by DCS 2 on March 27, 2010, indicated, ?While working the AM shift, I have noticed a towel being placed under the door of a client?s room. This started about two weeks ago. There will also be a chair placed in front of the door also. The client is usually asleep when the chair and towel are in front of his room door.? A signed, written statement by DCS 3 on March 27, 2010, indicated, ?About a month ago I observed a table sitting in front of (Client A?s name) room door. I removed the table then checked on (Client A?s name). Didn?t see anything out of the ordinary. So I went to make breakfast.? A signed, written statement by DCS 4 on March 27, 2010, indicated, ?One time I saw a chair in front of (Client A?s name) room.? In an interview with DCS 1 on July 26, 2010, at 1:50 p.m., she stated that (Client A?s name) had aggressive behaviors (grabbing) and DCS 5 had placed the dining room table in front of (Client A?s name) bedroom door to keep him from exiting his room during the night. She further stated that it was a fire hazard, and (Client A?s name) was very strong. He could climb over it or push the table aside. In an interview with the FM on February 2, 2011, at 1:15 p.m., She indicated that DCS 5 had told DCS 1, that she had placed the dining table in front of (Client A?s name) bedroom door to keep him from coming out. DCS 1 further stated that DCS 5 was sleeping on the couch and that (Client A?s name) had grabbed DCS 5 before, and that?s why she placed the dining room table in front of (Client A?s name) bedroom door. A review of the facility?s ?EMPLOYEE CODE OF CONDUCT,? indicated: ??35. Sleeping while on duty?? was a violation of the Employee Code of Conduct and constituted a cause for discharge (termination).A review of the facility?s policy and procedure titled, ?Rights ? Protection From Abuse? indicated under: ?POLICY? ?It shall be the policy of this agency to fully protect the rights of the individuals for whom we provide services, any form of abuse and neglect will not be tolerated.? On February 2, 2011, at 2:40 p.m., a review of Direct Care Staff 5?s, ?NOTICE OF CHANGE IN EMPLOYEE STATUS? dated April 7, 2010, indicated under, ?COMMENTS (Final incident or reason for leaving) ABUSE INVESTIGATION AND VIOLATION OF CLIENTS RIGHTS WAS SUBSTANTIATED.? Therefore, the facility failed to ensure Client A was free from unnecessary restraint by placing the dining table in front of Client A?s bedroom entrance/exit door.The above violations jointly, separately, or in any combination had a direct or immediate relation to Client A?s health, safety, or security. |
| 250000041 |
THE BRADLEY GARDENS |
250010547 |
B |
18-Mar-14 |
7XVE11 |
4384 |
"B" citation Health & Safety Code 1418.91. (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. The facility failed to report to the California Department of Public Health's (CDPH) office that a CNA had allegedly raped Patient A on 3/23/13.On 4/9/13, an unannounced visit was made at the facility to investigate a report of a Certified Nursing Assistant (CNA) who had allegedly raped Patient A on 3/23/13. On 4/9/13, at 9:45 a.m., an interview with the Director of Nursing (DON) was conducted. She stated that on 3/23/13, Registered Nurse (RN) 1 called her and told her that Patient A had called 911, and reported that an unknown CNA allegedly raped her (Patient A) in the bathroom two weeks ago. The police came, but there was no police report generated, as Patient A was known to fabricate stories. The DON stated that the Administrator was aware of the incident and had asked RN 1 to investigate the incident. The investigation was done, and it failed to substantiate any abuse so it was not reported to the licensing and certification office. The DON stated, "She (Patient A) has dementia (memory problems)." On 4/9/13, at 10 a.m., an interview with Patient A was conducted. Patient A stated that she was in the bathroom when a CNA asked her if she needed help. She stated, "No, I can do it myself. She (CNA) stuck her three fingers in my vagina. She had no reason to do that to me. She was happy she did it." Patient A stated that she called 911 and reported the incident and reported the alleged incident to RN 1. Patient A was asked who the CNA was, and she stated, "I don't know." On 4/9/13, at 10:15 a.m., an interview with RN 1 was conducted and she stated that Patient A was on the phone at the nurse's station, when she (RN 1) overheard Patient A was saying that she had been raped two weeks ago. RN 1 talked to Patient A and the patient told her she (Patient A) was raped by CNA 1 in the bathroom two weeks ago. RN 1 stated, "The patient does not know who the CNA, who allegedly raped her." RN 1 said, "She (Patient A) has (memory problems) dementia." RN 1 stated the DON asked her to investigate the incident. The investigation was done and it failed to substantiate any abuse. On 4/9/13, at 10:30 a.m., CNA 1 was interviewed. She stated that Patient A was alert but often got confused. On 4/9/13, at 11:20 a.m., Patient B (Patient A's roommate) was interviewed. She stated that she did not believe the incident had happen. She stated Patient A was in too much stress and worried a lot. She stated, "She (Patient A) is often confused and talks different things most of the times." On 4/9/13, at 12:30 p.m., the Executive Director (ED), who was in charge of the facility on that day, was asked why the incident was not reported to the Department. The ED stated, "The case was alleged abuse, and an investigation was done. The DON and the licensee were notified. The police and the ombudsman came over. It was a miscommunication on our part. We thought what we did was enough." The ED further stated that the investigation was done, and it failed to substantiate any abuse. On 4/9/13, Patient A's record was reviewed. Patient A was admitted to the facility on 10/10/02, with diagnoses including dementia (memory problems) and psychosis (loss of contact with reality including false beliefs and/or seeing and/or hearing things that aren't there). The admission notes indicated Patient A was alert with moderate to severe confusion related to dementia. On 4/16/13, at 10:17 a.m., the facility's Policy/Procedures (P/P) for "Reporting Abuse to State Agencies and Other Entities/Individuals" was received by fax. A review of the P/P indicated "...1. Should a suspected violation or substantiated incident of mistreatment...or abuse be reported, the facility Administrator or his/her designee, will promptly notify...a. The state licensing/certification agency responsible for surveying/licensing the facility...2. Verbal/written notices to agencies will be made within twenty-four (24) hours of the occurrence of such incident..." Therefore, the facility failed to report to the CDPH, that the CNA had allegedly raped Patient A on 3/23/13. The above violation had a direct or immediate relationship to the health, safety or security of the patient. |
| 250000095 |
The Grove Care and Wellness |
250011909 |
B |
19-Jan-16 |
C6UM11 |
4245 |
483.13 (c)(1) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. 482.13 (c)(2)The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (according to the State survey and certification agency). The facility failed to ensure a Certified Nursing Assistant (CNA 2) reported an allegation of abuse by a second CNA (CNA 1), toward Resident A to the facility Administrator immediately. This failure resulted in a delayed facility investigation and created a potential for further abuse.On August 31, 2015, at 1:55 p.m., an unannounced visit was made to the facility to investigate an entity reported incident that CNA 1 slapped Resident A on the face on August 12, 2015. During an interview conducted with CNA 2 on August 31, 2015, at 3:41 p.m., he stated he was walking in the hallway where Resident A?s room was located and heard crying. Upon investigation, he saw Resident A sitting in the wheelchair crying. Resident A pointed at her head and indicated by signs and gestures that someone had hit her head. When CNA 1 came into the room, Resident 1 became very upset, and called CNA 1 a ?criminal? and demanded for someone to call the police. CNA 2 stated he concluded something happened to Resident A; possibly that somebody hit her. CNA 2 stated he did not believe Resident A?s roommate was a reliable source of information, so he did not question her. CNA 2 stated he did not see any marks or bruises on Resident A. CNA 2 stated he did not report the incident to the administrator. CNA 2 stated he told a peer, CNA 3, that he suspected CNA 1 did something to hurt Resident A, but it was a suspicion, he had no proof. During an interview conducted with the facility Administrator, on August 31, 2015, at 4:08 p.m., he stated CNA 3 reported the August 12, 2015 incident of alleged abuse to the Director of Staff Development (DSD), on August 17, 2015. During an interview conducted with the DSD on August 31, 2015, at 4:20 p.m., she stated CNA 3 reported the alleged incident to her. During a follow-up interview she conducted with CNA 2, he stated he did not see anything happen. CNA 2 told the DSD he thought CNA 1 hit Resident A due to the resident?s tears and statement. The DSD was unable to provide documentation to indicate the Department was informed of the alleged incident of abuse within 24 hours. On August 31, 2015, at 2:40 p.m., an interview was conducted with Resident A. The resident became agitated, shaking her head and waving her hand. She stated ?NO,? and refused to be interviewed.On September 16, 2015, the facility policy and procedure (P&P), dated March 2013, titled, ?Policies and Procedures Regarding Prevention, Reporting, and Correction of Inappropriate Conduct, Including Abuse, Neglect, and Mistreatment of Residents,? was reviewed.The P&P, indicated: ??Abuse Prevention and Reporting? Each and every employee of the facility is a mandated reporter of any allegation of abuse. When in doubt, report the suspected abuse. Immediately contact the abuse coordinator- the administrator- no matter what time of day. We are each responsible to prevent and report abuse?All alleged violations will be reported via phone or in writing within 24 hours to the State Licensing Agency and Long Term Care Ombudsman?The facility will report to the state nurse aide registry or licensing authorities any knowledge it has any actions by a court of law which would indicate an employee is unfit for service??On November 12, 2015, at 2:10 p.m., an interview was conducted with the facility Administrator who stated he was notified of the August 12, 2015 incident on August 17, 2015. He stated he did not know why he was not informed about the incident sooner.The failure of CNA 2 to report the alleged abuse toward Resident A immediately, per facility P&P, has a direct relationship to the health, safety, or security of all residents in the facility. |
| 250000095 |
The Grove Care and Wellness |
250012685 |
B |
31-Oct-16 |
KYXF11 |
9461 |
"B" Citation The Grove Care and Wellness 483.25 (h) FREE FROM ACCIDENT HAZARDS/SUPERVISION/DEVICES The facility failed to maintain the patients' environment in a safe manner when the WTA sounded and staff turned off the alarm by accessing the EBP, which was not locked to restrict access to only authorized individuals. This failure increased the potential for unauthorized individuals to access the breakers and turn them off and cause patient care devices to cease working as intended. These facility failures increased the potential for accidents and injury such as scalding among patients, staff members, and visitors. Detailed and Supportive The facility failed to maintain the patients' environment in a safe manner when: 1. The water temperature alarm (WTA - alarm panel) sounded, indicating it had detected multiple water temperatures which exceeded 120 degrees Fahrenheit (F), and staff turned off the alarm before checking to determine the water temperatures on the unit did not exceed 120 degrees F, which created the potential for scalding hot water to reach patients care areas resulting in patient injury/Burns. 2. The Electrical Breaker Panel (EBP-a system designed to prevent electrical overload) was not closed and locked, leaving the panel readily accessible to anyone on the unit including staff, residents, and visitors. During the environmental tour of the facility on November 2, 2016, beginning at 9 a.m., with the Maintenance Supervisor (MS), the following was observed: On November 2, 2016, at 9:15 a.m., the WTA was observed alarming. The temperature posted on the WTA was 125ø. The Assistant Director of Nursing/Director of Staff Development (ADON/DSD) was observed walking to the EBP. She opened the unlocked door, and switched off the breaker which controlled the WTA (turning the WTA completely). On November 2, 2016, at 10:30 a.m., the WTA alarmed and registered water temperatures at 125 degrees F. The MS was observed as he turned off the breaker for the WTA. After the WTA was turned off, there was no water temperature monitoring observed as being conducted on the unit. Water temperature above 124 F may result in third degree burns (Full thickness injury which extends to the layers of the skin with possible nerve damage) when skin comes in contact for more than three minutes. A concurrent interview was conducted with the Licensed Vocational Nurse (LVN 1). He stated during the last week the WTA alarmed twice during the afternoon shifts. LVN 1 did not indicate water temperatures were checked after the WTA alarmed. An interview was conducted with the MS on November 2, 2016, at 10:40 a.m. He stated two weeks ago the mixing valve was replaced, but there was no system in place to calibrate the new mixing valve and there was no manual for WTA, so the WTA was not accurately reflecting accurate temperatures of the water. On November 2, 2016, at 11 a.m., the WTA was observed as turned off. On November 2, 2016, at 11:15 a.m., an interview was conducted with the MS regarding the WTA, which was turned off. The MS stated he noticed yesterday and today the WTA was turned off and stated, "May be someone turned it off." On November 2, 2016, the temperature posted on the WTA was as follows: 2:24 p.m., registered 125 degrees F; 2:25 p.m., registered 126 degrees F; and 3 p.m., registered 122 degrees F. On November 3, 2016, beginning at 6:30 a.m., the temperatures posted on the WTA was observed registered at 130 degrees F, 124 degrees F, 123 degrees F, and 126 degrees F. On November 3, 2016, at 7:30 a.m., the MS turned off the WTA. He further stated the WTA was not working properly. The MS did not state how he knew the temperatures displayed on the WTA were incorrect. On November 3, 2016, at 10:15 a.m., an interview was conducted with the ADON/DSD regarding the WTA, which was observed alarming (audible alarm system sound), and the observation of the ADON/DSD as she opened the EBP and turned off the breaker of the WTA on November 2, 2016. The ADON/DSD stated she turned off the alarm to quiet it and help keep the patients calm. On November 3, 2016 at 2:45 p.m., in an interview with the ADON/DSD, she stated the WTA had not been functioning "right" (as designed) for several months. She stated she switched off the breaker in the EBP to turn off the alarm. She further stated she was aware she should not switch off the breakers in the EBP. On November 4, 2016, between 8 a.m. to 9 a.m., the WTA alarmed. The water temperatures posted on the WTA indicated the water temperatures were registered at 129 degrees F and 128 degrees F. An interview was conducted with the Administrator on November 4, 2016, at 9:15 a.m., he stated the WTA came with the building and the facility did not have manufacturer's guidelines available for the maintenance department. On November 4, 2016, the facility MAINTENANCE DEPARTMENT REPORT dated June 15, 2016, was reviewed. The report indicated, "....Working on hot water temperature alarm-covering and adjusting for proper alarming...." On November 7, 2016, the report from OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT (OSHPD), "CONSTRUCTION ADVISORY REPORT- Field Notes," dated September 13, 2016, was reviewed. The reports indicated, "....During walk it was noticed that the hot water alarm for domestic water is not functioning (violating Title 24 part 5 section 613.5), that may pose a scalding hazard to patient and staff, ..." On November 3, 2016, facility policy and procedure (P&P)) titled, "High limit water temperature procedure," was reviewed. The policy indicated, "It is the policy of this facility to maintain water temperatures. For hot water used by patients, there shall be temperature controls to automatically regulate the temperature to maintain below 120 degrees F. Procedures: If the hot water high-limit audible alarm system sounds and shows temperature out of range: 1. Silence the alarm and immediately check the water temperature. Continue checking the water temperature every 30 minutes until the Maintenance Director (DM) or designee check the system and reset the alarm..... 3. If the water temperature is found to be out of range, notify residents not to use hot water. Notify the DM immediately. Continue checking the water temperature every 30 minutes until the MD or designee check the system and reset the alarm.... 4. Any time the hot water high-limit audible alarm is sounded notify the DM." The facility failed to ensure the hot water monitoring system was functional to ensure the residents were free from the risk for scalding. In addition, when the hot water monitoring system was not reliably functioning from June 2016 through November 2016, and the alarm frequently was set off, the facility failed to implement their policy and procedure for monitoring water every 30 minutes until the alarm was reset by the MS. This failure increased the potential for resident injury from water that exceeded 120 degrees F. 2. On November 2, 2016, at 9:15 a.m., the WTA was observed alarming. The temperature posted on the WTA was 125ø. The Assistant Director of Nursing/Director of staff Development (ADON/DSD) was observed walking to the EBP. She opened the unlocked door, and switched off the breaker that controlled the WTA (turning the WTA off completely). On November 2, 2016, at 9 a.m., an interview was conducted with OSHPD Compliance Officer (CO1), who stated electrical breaker panels are required to be kept locked and secure in order to prevent access by any unauthorized person. CO1 defined an authorized person as someone who needed to access the box for repairs, such as electrician or the maintenance department. CO1 stated no other person should have access to the electrical breaker panel. On November 2, 2016, at 11:20 a.m., an interview was conducted with the Maintenance Supervisor (MS). The MS stated the EBP was not locked due to the workers (electrician, elevator and Alarm Company) who might need access to the panel because the facility was currently bringing electrical "up to code." On November 3, 2016, at 10:15 a.m., an interview was conducted with the ADON/DSD regarding the WTA, which was observed alarming (audible alarm system sound), and the observation of the ADON/DSD when she opened the EBP and turned off the breaker for the WTA on November 2, 2016. The ADON/DSD stated she turned off the alarm to quiet it and help keep the patients calm. On November 3, 2016 at 2:45 p.m., in an interview with the ADON/DSD she stated the WTA had not been functioning "right" (as designed) for several months. She stated she switched off the breaker in the EBP to turned off the alarm. She further stated she knew she should not be switching off the breakers in the EBP. An interview was conducted with the Administrator on November 4, 2016, at 9:15 a.m. He stated the EPB near the nursing station should be kept unlocked and accessible for the staff during emergencies. He further stated there was no requirement to keep the EPB "locked." The facility failed to maintain the patients' environment in a safe manner when the WTA sounded and staff turned off the alarm by accessing the EBP, which was not locked to restrict access to only authorized individuals. This failure increased the potential for unauthorized individuals to access the breakers and turn them off and cause patient care devices to cease working as intended. This violation had a direct relationship to the health, safety, or security of patients. |
| 910000336 |
The Rehabilitation Center of Santa Monica |
910008898 |
B |
11-Jan-12 |
X25Z11 |
7637 |
72311-Nursing Service- General (3)(F) Notifying the attending physician promptly of any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient. 72313- Nursing Service- Administration of Medications and Treatments (a)(2) Medications and treatment shall be administered as prescribe.The Department received an anonymous complaint on December 2, 2011, alleging Patient 1 was receiving an overdose of antibiotics. On December 9, 2011, at 8:30 a.m., an unannounced visit was made to the facility to investigate the allegation. Based on interview, record review, and review of RN 1 and the director of nursing?s (DON) declaration, the facility failed to: 1. Ensure an antibiotic, Ciprofloxacin (Cipro) was administered as prescribed by the physician. 2. Inform the patient?s primary physician of the significant medication error. 3. Follow the facility?s policy on reporting medication errors. These failures resulted in a significant medication error and had the potential for serious harm and health risk to Patient 1, who had a diagnosis of end stage renal disease (ESRD) and required dialysis (a process which removes toxins from the body) three times a week. The patient received 900mg of Cipro instead of 500mg as prescribed by the physician. RN 1 failed to inform the physician of the significant medication error, which put Patient 1 at an increase risk for drug toxicity (excessive amount of a drug), hepatic impairment (reduce liver function), and seizures (abnormal electrical activity of the brain).On December 9, 2011, a review of Patient 1?s, clinical record (Face Sheet) indicated the patient was a 72 year-old admitted to the facility on November 21, 2011. The patient?s diagnoses included end stage renal disease (failure of the kidney to function), diabetes (high levels of sugar in the blood), and hypertension (increased blood pressure). The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated November 27, 2011, indicated the patient was able to make himself understood and understands other. According to the MDS, the patient required extensive assistance from staff for activities of daily living (ADLs), such as transfers, bed mobility, ambulation, and toilet use. According to the patient?s admission orders, dated on November 21, 2011, time not indicated, the physician ordered Cipro 400mg via intravenous (into the vein [IV]) every 24 hours for seven days. Another physician?s telephone order, dated November 21, 2011 timed at 9:30 p.m., indicated Cipro IV was discontinued and changed to Cipro 500mg by mouth once a day for seven days.On December 9, 2011, a review of the investigation report of RN 2 interview record, indicated Patient 1 received the first dose of Cipro 500mg by mouth from the E-kit (emergency kit) on November 21, 2011 at 9:40 p.m.During an interview, on December 9, 2011, at 9:50 a.m., Patient 1 stated he informed his nurse (RN 2) that he prefers to take the pills form of antibiotic rather than the IV.On December 9, 2011, a review of a nurse?s note, dated November 21, 2011, timed at 9:30 p.m., indicated RN 2 called Patient 1?s physician and informed him about the patient?s request. As a result, the physician discontinued the IV antibiotic and started the antibiotic (cipro) by mouth (p.o).On December 9, 2011, a review of RN 1?s employee file, indicated in August 2010, she was given a verbal warning about failing to follow proper discharge of a patient.Another entry also noted on December 8, 2011, RN 1 was given a final written warning regarding failing to check discontinued medications. Also, in the file was a one-to-one inservice/training for proper medication administration, the Director of Nurse (DON) noted that RN 1 refused to sign off the inservice and walked out of the office. During an interview, on December 9, 2011, at approximately 10:50 a.m., the registered nurse supervisor (RN 1) stated she inserted a heplock (a catheter that is inserted into a vein to administer intravenous medication), but could not recall a specific date. She also stated, ?I never gave the Cipro IV antibiotic.? RN 1 further stated she discontinued the heplock after she found out that Patient 1 was started on Cipro antibiotic by mouth. When asked if she had charted this in the nurses notes, RN 1 stated, ?No I didn?t and the IV piggy bag MAR for Patient 1 is missing.? Ten minutes into the interview, RN 1 recanted her statement and stated, ?I did give one dose of the Cipro IV antibiotic to the patient on November 23, 2011, 2 days after the IV Cipro was discontinued.? When the RN was asked, did you chart the Cipro IV that you gave, RN stated ?No.? When RN 1 was asked, what should she have done when you realized Patient 1 was receiving the Cipro antibiotic by mouth and the IV Cipro, RN stated, ?I should have called the doctor about the medication error, notify the family, and report the incident to the DON.? During an interview, on December 9, 2011, at 1:20 p.m., the DON stated, ?I talked to RN 1 about the incident and she was giving me an attitude about it.? The DON also stated, ?It is serious what she did by not reporting the significant medication error.? When the DON was questioned about what RN 1 should have done, she stated RN 1 should have notified the physician, patient?s family, and reported the incident to her.On December 12, 2011, at 9:40 a.m., during a telephone interview, a supervising pharmacist from the dispensing pharmacy, was asked how many Cipro IV piggy bags were dispensed to the facility for Patient 1. The pharmacist stated two intravenous piggy-backs of Cipro antibiotic, and one came from the emergency kit (E-kit). When asked if the pharmacy received any Cipro IVPB that were returned to the pharmacy from the facility, he stated, ?No.?On December 13, 2011, at 9:33 a.m., in a telephone interview, Patient 1?s primary physician stated he should have been informed of the medication error once it was identified, so he could have seen the patient and spoken to the family. The physician also stated the patient had end stage renal disease and that was why he only received Cipro antibiotic once a day. The physician also stated the Cipro antibiotic maximum dose per day was 750mg and the patient received 900mg.A review of the Medication Variance Report, dated December 8, 2011, which was 17 days after RN 1 gave the wrong dose of Cipro, indicated she was suspended on December 9, 2011 for not reporting the medication error.A review of the facility?s policy titled, ?General Dose Preparation and Medication Administration?, dated on December 18, 2006, indicated the facility?s staff should verify each time a medication was administered, that it is the correct drug, at the correct dose, the correct route, at the correct rate, at the correct time, and for the correct resident.A review of another policy titled, ?Incident Reporting for Residents or Visitors,? dated August 15, 2001, indicated medication errors are reported on the Medication Error Report. In addition, the policy stipulated in events involving residents, pertinent clinical information and observations must be recorded in the progress notes, which was not done because RN 1 failed to report the medication error. The facility failed to: 1. Ensure an antibiotic, Ciprofloxacin (Cipro) was administered as prescribed by the physician. 2. Inform the patient?s primary physician of the significant medication error. 3. Follow the facility?s policy on reporting medication errors. The above violations had a direct relationship to the health, safety, or security ofPatient 1. |
| 910000036 |
THE EARLWOOD |
910009344 |
A |
10-Jul-12 |
PD1S11 |
8723 |
F323 42 CFR 483.25(h) Accidents The facility must ensure that the resident environment remains as free of accident hazard as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On December 31, 2009, the Department received an Entity Reported Incident from the facility indicating on December 28, 2009 at 10:40 p.m. Resident 1 was found not to be in his room. According to the report, the facility staff searched the facility and the surrounding grounds but was unable to locate Resident 1. The police and family were then notified that Resident 1 was missing from the facility.Based on observation, interview, and record review, the facility failed to ensure Resident 1, who was assessed and identified at risk for elopement, received adequate supervision and was provided a safe environment by failing to: 1. Monitor Resident 1?s whereabouts to ensure he did not leave the facility unattended. 2. Ensure the facility?s door alarm system was not disabled, and would activate (sound) when someone opened the alarmed door, to ensure a safe environment, as indicated in the facility?s policy and procedure. As a result, on December 29, 2010 at 3 a.m., Resident 1 was found wandering in the residential area with swelling above his left eye and blood dripping down his nose by the police department. The paramedics were called and the resident was treated at the scene, and was later transferred to the general acute care hospital (GACH). The resident sustained a scalp hematoma (a localized swelling that is filled with blood caused by a break in the wall of a blood vessel) in the left frontal region of his head and abrasions to his forehead and to bilateral knees. On January 15, 2010, a review of the admission record indicated Resident 1 was an 83 year-old male admitted to the facility on December 3, 2009, with diagnoses that included psychosis (a loss of contact with reality about what is taking place or who one is, and seeing or hearing things that are not there), syncope (a sudden usually temporary loss of consciousness generally caused by insufficient oxygen in the brain) and dementia (progressive deterioration in cognitive function). The record indicated Resident 1 was discharged home with his family on January 8, 2010.A review of the Elopement Risk Assessment dated December 3, 2009, indicated Resident 1 was at risk for elopement. A care plan was initiated on December 3, 2009, indicating the resident was at risk for wandering and possible elopement due to newly admitted to the facility, dementia, and confusion. The goal was for the resident not to leave the facility unattended. The approaches included to monitor the resident?s whereabouts and to provide diversional activities. The plan of care did not indicate how often the resident?s whereabouts would be monitored, or who was responsible for monitoring the resident.The Minimum Data Set (a standardized assessment tool) dated December 16, 2009, indicated the resident was moderately impaired in cognitive skills for daily decision making with memory problems. The resident was also assessed as requiring extensive assistance from staff for all activities of daily living and dependent on staff for toilet use. The resident?s primary mode of locomotion was by wheelchair. The General Case Report for Incident obtained from the PD dated December 30, 2009, indicated Resident 1 was found on December 29, 2009, at 3 a.m., wandering in the residential area with swelling above his left eye and blood dripping down his nose. According to the report the paramedics were called, Resident 1 was treated at the scene and was later transferred to the GACH. The Computed Tomography [(CT) a special x-ray of the head to detect skull fractures, bleeding, or brain injury in residents with head trauma] of Resident 1?s head obtained from the GACH indicated the resident sustained a scalp hematoma [a localized swelling that is filled with blood caused by a break in the wall of a blood vessel] in the left frontal region of his head. The report also indicated Resident 1 had abrasions to his forehead and to both of his knees.On January 15, 2010 at 12 noon, the facility?s surveillance camera recording from December 28, 2009, was reviewed with the maintenance supervisor. Resident 1 was observed walking out of his room pushing his wheelchair. Resident 1 was later observed on the recording exiting through the North East door pushing his wheelchair. There was no staff member observed pursuing Resident 1 as he exited the door.On January 15, 2010, interviews were conducted with Licensed Vocational Nurse 1 (LVN 1), LVN 2, and the Director of Nurses (DON) from 12:30 p.m. to 1:05 p.m. It was established that Resident 1 was last seen in the north station hall around 10:00 p.m. on December 28, 2009, by LVN 1 when he was passing medications. When LVN 2 made her rounds at 11:10 p.m., Resident 1 was not in his room. LVN 2 stated she reported this to the Registered Nurse (RN 1). The DON stated that the surveillance camera recorded Resident 1 leaving the facility through the North East door on December 28, 2010. The DON stated the door alarm had been disabled by someone, but did not know who. A review of the Facility Investigation Report dated December 28, 2009, indicated at approximately 11:45 p.m., Resident 1 was noted to be missing from the facility by the 11 p.m. to 7 a.m. charge nurse. The note indicated the staff searched the whole building and surrounding area, but did not locate Resident 1. The resident?s wheelchair was found in the community. The investigation report did not address why the resident was in the north station hallway at 10 p.m., or who was responsible for the resident?s whereabouts. It did not address the operation or disabling of the alarm system at the time the incident occurred, who was responsible, or whether the door alarm sounded or not at the time of the incident. There was no documented evidence that the surveillance video had been viewed by the administrative staff to establish timelines or evidence of why the incident occurred.A review of the "Witness Statement (Continued)" completed December 29, 2009, at 6:45 p.m. by the facility staff, conducted with Resident 1 and his daughter, after his return to the facility, revealed that the resident did not remember what happened to him. It was documented that he complained of pain to his knees, and was given Vicoden for the pain. His appearance was documented as having left and right (head) frontal area discoloration, with left side swelling, and discoloration to the bridge of his nose. The plans were to discharge him home with his family.The facility?s Elopement policy and procedure revised June 9, 2008, indicated it is the policy of the facility to protect residents (residents) from wandering away from the facility. The purposes included to protect residents that are not capable of protecting themselves, and to provide the techniques and equipment to minimize safety risks. Under the Prevention section, it was indicated that the disabling of the alarm system will only be authorized by the administrator or designee, and a method for monitoring of residents? safety would be established until resetting the alarm system. A review of the Communication letter between the administrator and the maintenance supervisor dated December 29, 2009, indicated the maintenance supervisor verified the door alarm on the North East door (where Resident 1 exited) was functional. The facility failed to ensure Resident 1, who was assessed and identified at risk for elopement, received adequate supervision and was provided a safe environment by failing to: 1. Monitor Resident 1?s whereabouts to ensure he did not leave the facility unattended. 2. Ensure the facility?s door alarm system was not disabled, and would activate (sound) when someone opened the alarmed door, to ensure a safe environment, as indicated in the facility?s policy and procedure. As a result, on December 29, 2010 at 3 a.m., Resident 1 was found wandering in the residential area with swelling above his left eye and blood dripping down his nose by the police department. The paramedics were called and the resident was treated at the scene, and was later transferred to the general acute care hospital (GACH). The resident sustained a scalp hematoma (a localized swelling that is filled with blood caused by a break in the wall of a blood vessel) in the left frontal region of his head and abrasions to his forehead and to bilateral knees. The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 910000036 |
THE EARLWOOD |
910009565 |
A |
07-Jan-13 |
XDBK11 |
9096 |
F323483.25(h) AccidentsThe facility must ensure that ? (1) The resident environment remains as free from accidents hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents.The facility failed to ensure Resident A, who was assessed with weakness to both lower extremities (legs), was totally dependent on staff for bed mobility and transfers, and required two-plus persons physical assist for transfers, was transferred safely from her bed to a shower chair. The facility also failed to implement their policies entitled ?Lifting and Transferring of Residents? and ?Gait Belt Policy,? to prevent accidents,and ensure assistive devices were utilized for safe transfers, and when developing Resident A's care plan. These failures resulted in the resident sustaining a right lower leg fracture and cut to her second toe.On October 26, 2009, at 3:05 p.m., an unannounced visit was conducted to investigate an Entity Reported Incident (ERI) from the facility. The ERI indicated that on August 8, 2009, at or about 7 p.m., Resident A slipped from the bed to the floor during transfer, which resulted in a fractured (broken) right leg and bleeding to her right foot.A review of the medical record revealed Resident A was a 75 year-old female readmitted to the facility on July 2, 2009, with diagnoses including diabetes mellitus (high blood sugar), end stage renal disease (kidney failure) with hemodialysis treatment (a mechanical filtering process to remove products from the blood when the kidneys are unable to do this on their own), hypertension (high blood pressure) and osteoarthroses (loss of cartilage in the joints). According to the Nursing Admission and Assessment Sheet, dated July 2, 2009, Resident A?s actual weight was 170 pounds. She was five feet six inches tall and had musculoskeletal weakness to her legs.A Fall Risk Assessment dated July 3, 2009, indicated Resident A was considered a high risk for falls. The Minimum Data Set (MDS), a standardized assessment and care screening tool, dated July 8, 2009, indicated Resident A had modified independence in her cognitive skills for daily decision making, was totally dependent on staff requiring two-plus persons assist for transfers, toilet use, and bathing. The resident was assessed as non-ambulatory and had limitations in her range of motion to her hands, legs, and feet, with partial loss of voluntary movement, and she was unable to balance while sitting or standing without physical help.Care plans were initiated on July 3, 2009. The care plan for falls as manifested by dizziness/vertigo and poor safety judgment, had a goal for the resident not to have injuries due to falls. The approaches did not include how the resident would be transferred safely. The care plan for activities of daily living (ADL) maintenance had a goal which included the resident would not have a fall/injury daily. The approaches included to assist the resident with all transfers as needed (PRN). However the method of transfer and the equipment necessary for a safe transfer was not addressed in the care plan in accordance with the MDS assessment and the facility?s policies.The Occupational Therapy (OT) initial evaluation dated July 9, 2009, ?Functional Transfer? indicated the resident required maximum assist for rolling in bed mobility, had a decline in supine (lying on the back with the face upward) to a sit position, and required total assist with two person assistance during transfer between the bed and gurney. The evaluation did not address the resident?s ability to transfer from the bed to a chair or to a shower chair. A review of the PPS (Prospected Payment System) Licensed Notes dated August 6, 2009, and August 7, 2009, indicated Resident A had weakness in her lower extremities.According to the ?Daily and Q Shift Charting? licensed nurses notes dated August 8, 2009, at 7 p.m., the certified nursing assistant (CNA) reported that the resident was crying and her toe was bleeding. When asked by the licensed nurse what happened, the resident stated she did not know what happened, but she was on the ground, and now her knee hurt. She reported a pain level of 10 on a scale of 1 to 10 (10 being the worst pain a person can have). The note indicated Resident A was given Lortab (narcotic pain medication) for pain and the toe was wrapped with dressing.At 7:30 p.m., the notes indicated the shower was completed and the resident was placed back to bed and upon assessment, a 3 inch by 4 inch discoloration with purple center and edges were noted on the resident?s right lower leg. The resident?s right lower leg could not be moved without the resident screaming. The physician was notified and an order was obtained to transfer the resident to the general acute care hospital (GACH). The right leg x-ray result obtained from the GACH dated August 9, 2009, indicated proximal tibial and fibula [bones in the lower legs] fracture. The history and physical obtained from the GACH dated August 9, 2009, indicated Resident A had a large hematoma (a ruptured blood vessel) about 10 centimeters (cm) by 10 cm on the right upper shin area next to the knee, slight swelling of the knee, and a cut on the toe of the right foot. The surgeon discussed possible surgery on the right lower extremity to release the hematoma, however Resident A refused any kind of surgery. The surgeon then performed an incision and drainage (cut and drain) of the hematoma at the bedside.A review of the statements documented on the Witness Statement forms dated August 8, 2009, given by CNA 1 and CNA 2, indicated that during the transfer, they sat Resident A at the edge of the bed and she began to slide, so they sat her on the floor. They stated Resident A was very heavy, and instead of picking the resident up and putting her back on the bed, they sat her on the floor. Once they got the resident in the shower chair, they noticed that ?blood was dripping from her toe? and she was complaining of knee pain.A review of the facility?s investigation report dated August 8, 2009, indicated the CNAs stated that upon transferring the resident from her bed to the shower chair, they sat the resident down on the ground because she was sliding out of their hands. The CNAs then placed the resident on the shower chair and proceeded to the shower room. It was documented the resident complained of knee pain and was medicated.On October 26, 2009, at 3:05 p.m., during an interview, CNA 1 stated she and CNA 2 sat Resident A up on the bedside and tried a two-person lift to transfer the resident from the bed to the shower chair. CNA 1 stated they could not lift the resident because she was too heavy and they repositioned her back onto the bed. CNA 1 stated she wasn?t sure if the resident was right at the edge of the bed, but after putting her back on the bed, the resident began to slide down toward the floor. CNA 1 stated both she and CNA 2 helped the resident to the floor but she could not remember what position the resident was in when she ended up on the floor. CNA 1 stated she was not used to working with Resident A, and was not told the resident had weakness in her legs and was non-ambulatory. It was stated that they did not use a ?lift? or a gait belt during the transfer of Resident A.According to the facility?s policies and procedures titled ?Lifting and Transferring of Residents? (no date), residents are to be lifted and transferred in a safe manner in all instances. Nurses are to assess and determine lifting and transfer requirements and procedures used for each resident; all residents must be lifted or transferred according to the determined procedure. Residents who require assistance in transferring are to be transferred using a gait belt or with a lift. Mechanical lift procedures are used on any resident unable to independently pivot or transfer. The designated method of lifting and transferring would be indicated on the MDS and in the resident?s plan of care, and adjustment would be made to the plan of care as needed. The ?Gait Belt Policy? (signed as received by CNA 1 on June 23, 2009) indicated gait belts are to be in the possession of all nursing assistants and are to be used when transferring residents. The policies were not implemented.The facility failed to ensure Resident A, who was assessed with weakness to both lower extremities, was totally dependent on staff for bed mobility and transfers, and required two-plus persons physical assist for transfers, was transferred safely from her bed to a shower chair. The facility also failed to implement their policies entitled ?Lifting and Transferring of Residents? and ?Gait Belt Policy,? to prevent accidents,and ensure assistive devices were utilized for safe transfers, and when developing Resident A's care plan. These failures resulted in the resident sustaining a right lower leg fracture and cut to her second toe.This 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 A. |
| 910000036 |
THE EARLWOOD |
910009957 |
B |
19-Jun-13 |
VFQH11 |
5769 |
Code of Federal Regulations 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 February 9, 2009, at 8:55 a.m., an unannounced visit was made to the facility to conduct an entity reported incident [(ERI) CA00175957] investigation regarding Resident A (patient) sustaining a deep laceration to her left foot after a transfer.Based on interview and record review, the facility failed to provide adequate supervision to Resident A in accordance with her assessment for requiring two-person assistance during transfers, and per the facility?s policy. Instead, Resident A was transferred by only one person and sustained a deep laceration on her left foot. Resident A was transferred to the general acute care hospital (GACH) where the wound was found to shell down to the bone of the foot requiring closure with continuous locked 4-0 nylon stitches to a total length of 5 centimeters (cm).Resident A was a 92 year-old female readmitted to the facility on February 15, 2008, with diagnoses that included paralysis agitans (Parkinson?s), diabetes mellitus (DM [a condition resulting in too much sugar/glucose in the blood]), and glaucoma (eye disease that impairs vision). A review of the Minimum Data Set (MDS), an assessment and care screening tool, dated October 5, 2008, indicated Resident A was totally dependent on staff for her activities of daily living (ADL) with the support of one person. A care plan dated October 6, 2008, for activities of daily living, indicated Resident A was totally dependent on staff with all her ADLs including transfers. The goal was for Resident A to have no falls or injury daily. The approaches included to assist the resident with all transfers as needed (PRN). The number of person assistance required to transfer the resident was not addressed. According to the Physical Therapist Daily Documentation dated January 16 to 22, 2009, Resident A required maximum two-person assistance with transfers from the bed to the wheelchair. A review of a facility investigative report dated January 24, 2009, indicated Resident A sustained a skin tear when her foot was caught in the wheel chair. On January 24, 2009, at 10:40 a.m., the certified nursing assistant (CNA) failed to call for assistance and/or utilize two-person assistance while transferring the resident from the bed to the wheel chair. At the time of the incident, Resident A was not wearing any protective footwear such as socks or shoes. Further review of the report indicated the laceration to the left foot was approximately 7 centimeters long and 1 1/2 inches deep. Risk factors documented on the investigative report included, ?the patient?s dependence on transfers requiring two-person assistance and the nursing assistant not following proper transfer techniques while caring for the patient.? According to the Emergency Department notes obtained from the GACH dated January 24, 2009, indicatedResident A had very limited range of motion in all of her joints. The notes indicated the resident had a very deep transverse laceration to the lateral left foot measuring approximately 5 centimeters (cm) long, approximately 2 cm anterior to the lateral malleolus. The resident was given anesthesia, and the wound was irrigated and explored. The wound was found to shell down to the bone of the foot. The wound was then closed with continuous locked 4-0 nylon stitches to a total length of 5 cm. After the procedure Resident A was placed on prophylactic intravenous antibiotics. The Interdisciplinary Team notes dated January 26, 2009, indicated the CNA involved (CNA 1) stated the resident?s leg became lodged next to the leg extensions on the wheelchair when she transferred the resident by herself, instead of using two-person assistance.CNA 1 was not available for an interview during the course of the complaint investigation. On February 9, 2009, at 8:55 a.m., the director of nursing stated Resident A required a two-person assist with transfers because the resident had contractures to her lower extremities.On February 9, 2009, at 9:15 a.m., during an interview the physical therapist stated he was familiar with Resident A and had provided her with therapeutic exercises. He had transferred the resident from the bed to her wheel chair on more than one occasion, providing assistance to the nurses. He stated Resident A required two-person assist with transfers. The therapist stated he trained and observed several nursing assistants and licensed staff transfer Resident A from the bed to the wheelchair A facility undated policy and procedure on Lifting and Transferring of patients indicated: ?Nurses should assess and determine lifting and transfer requirements and the procedure for each resident. All patients must be lifted or transferred according to the determined procedure and all members of the nursing staff and nursing assistants are responsible for knowing the proper procedures.? The facility failed to provide adequate supervision to Resident A in accordance with her assessment for requiring two-person assistance during transfers, and per the facility?s policy. Instead, Resident A was transferred by only one person and sustained a deep laceration on her left foot. Resident A was transferred to the GACH where the wound was found to shell down to the bone of the foot requiring closure with continuous locked 4-0 nylon stitches to a total length of 5 cm.The failure of the facility to ensure Resident A was transferred using two-person assistance from the bed to the wheel chair had a direct relationship to the health, safety, and security of Resident A. |
| 910000336 |
The Rehabilitation Center of Santa Monica |
910009958 |
B |
20-Jun-13 |
SC1P11 |
9606 |
F322 ?483.25 (g) Based on the comprehensive assessment of a resident, the facility must ensure that -- (2) A resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills. The Department received an anonymous complaint on May 31, 2012, alleging a resident?s (Resident 1) gastrostomy feeding tube (G-Tube) was found out and the registered nurse (RN) supervisor went against the facility?s policy and re-inserted the G-Tube. On June 14, 2012, an unannounced complaint investigation was conducted. Based on interview and record review, the facility failed to:1. Provide appropriate care, treatment, and services for prevention of Resident 1?s G-tube being pulled out after the resident pulled it out twice within 14 days. 2. Follow the facility?s policy in obtaining a physician?s order for re-insertion of a G-tube. 3. Update the resident?s plan of care after the resident pulled out the G-tube on May 28, 2012, and again on June 10, 2012.These failures resulted in bleeding from Resident 1?s G-Tube site and the resident being transferred to a general acute care hospital (GACH) twice for G-tube re-insertion. The facility?s staff re-inserting the G-tube had the potential to result in the tube being improperly placed and causing multiple complications. On June 14, 2012, a review of Resident 1?s record indicated the resident was an 88 year-old originally admitted to the facility on April 19, 2008, with the latest re-admission on June 5, 2012. The resident?s diagnoses included cerebral vascular accident (CVA/ rapid loss of brain function due to disturbance in the blood supply to the brain) with left side weakness and aphasic (partial or total inability to produce and understand speech as a result of brain damage), seizure disorder (sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological), dementia (loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior) and dysphagia (difficulty in swallowing) with a G-tube (placement of a feeding tube through the skin and the stomach wall, directly into the stomach). A review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated May 3, 2012, indicated the resident had memory problems and was not able to express her needs and understand others. According to the MDS, Resident 1 was non-ambulatory and was totally dependent upon the staff for all care. On June 14, 2012, a review of the recapped physician?s orders for the month of May 2012, indicated to check the tube placement/patency every shift, check residual prior to each feeding of Jevity 1.2 formula infusing at 55cc/hour for 20 hours and flush tube pre/post medications and every shift. A review of a Nurse?s Note, dated May 28, 2012, and timed at 11:45 a.m., indicated the registered nurse (RN) supervisor noted Resident 1?s G-tube pulled out and lying at the resident?s side. The note indicated the RN supervisor informed the charge nurse (Charge Nurse 1) and the RN re-inserted Resident 1?s G-Tube. There was no documented evidence the resident?s physician ordered the G-tube to be re-inserted, as per the facility?s policy. The note further indicated at 11:50 a.m., the physician was notified and the nurse was waiting for a returned call. Another Nurse?s Note, dated May 28, 2012, and timed at 12:40 p.m., indicated the resident?s physician called back and gave an order for the resident to be transferred to the GACH. Resident 1 was transferred at 1:20 p.m. per ambulance. A review of another Nurse?s Note, dated June 10, 2012, and timed at 11:25 a.m., indicated the charge nurse notified the RN supervisor that the resident had pulled the G-tube out. According to the note, the G-tube site was cleaned and a dressing was applied and the physician notified. The physician called back at 11:40 a.m., and gave an order for the resident to be transferred to the GACH. At 12:20 p.m., Resident 1 was transferred to the GACH via ambulance. Resident 1 returned to the facility that evening at 5:30 p.m. On June 14, 2012, at 7:30 a.m., during an interview, the director of nurses (DON) stated it was the second time Resident 1 pulled her G-tube out and it was the facility?s policy to not re-insert the tube, but to send the resident to the hospital. When the DON was asked if any of the staff re-insert the G-tube, the DON stated, ?None of our staff tried to replace the tube after the first time in May.? A care plan, dated November 6, 2011, titled Feeding Tube/Dysphagia, had no interventions to prevent the resident from pulling out the G-tube. The plan of care that was last updated May 2012 was not revised on May 28, 2012, after the resident pulled the tube out. The DON was interviewed again on June 14, 2012, at 9:30 a.m. after reviewing the resident?s plan of care, and stated they should have included the use of an abdominal binder on the care plan after the May 28, 2012 incident to prevent dislodgement of the G-tube.At 10:50 a.m., on June 14, 2012, Charge Nurse (CN) 2 was interviewed and asked what she would do if a resident pulls out the G-tube. CN 2 stated she would call 911 to transfer the resident to the hospital. CN 2 stated, ?We can?t put it back or put anything in. We need to call the hospital.? On June 14, 2012, at 11:05 a.m., during an interview, CN 2 stated she was on duty both times Resident 1 pulled out her G-tube (May 28 and June 10, 2012). CN 2 stated she went to assist her co-worker on May 28, 2012, after the resident pulled the tube out. CN 2 stated CN 1 asked her what to do and she stated she informed CN 1 to call the physician because they were not supposed to re-insert the G-tubes. CN 2 stated CN 1 told her the RN supervisor had re-inserted the G-tube. CN 2 stated that they had been given in-services regarding G-tube replacement,and the policy states if the tube comes out to contact the physician and transfer the resident to the hospital. At 11:35 a.m., the facility?s director of staff development (DSD) stated the charge nurses have the responsibility of updating the residents? care plans and the RN should make sure it is done. When the DSD was asked what the nurses? responsibility was when a G-tube was dislodged or pulled out the DSD stated, ?We expect them to transfer the resident immediately and not to re-insert.? On June 14, 2012, at 12:35 p.m., an interview was conducted with the RN Supervisor, who re-inserted Resident 1?s G-tube after it was pulled out on May 28, 2012. The RN stated she tried to re-insert the G-tube but it wouldn't work, and because she thought it was the policy. She stated she called the DON and was told it was not their policy, so she pulled the G-tube back out. On June 18, 2012, at 1:30 p.m., during an interview, CN 3 stated she was on duty on May 28, 2012. CN 3 stated the RN supervisor (RN) informed her and the treatment nurse (TN 1) that Resident 1?s G-tube was out. She stated she went to the resident?s room and informed the RN to transfer the resident and the RN stated, ?Not for this? I can re-insert it.? CN 3 stated the RN was informed not to re-insert the G-tube, but she re-inserted the G-tube anyway. CN 3 stated TN 1 placed a padded dressing over the G-tube site because it was bleeding. A review of the facility?s policy titled ?Gastrointestinal Tube Change/Reinsertion? updated July 28, 2009, indicated the first thing to do was to obtain a physician?s order for change or replacement of a tube. However, the facility?s RN supervisor failed to obtain a physician?s order for change or replacement of Resident 1?s G-tube, according to the facility?s policy. On May 17, 2013, a review of the GACH records for Resident 1 indicated the resident was transferred to the GACH on May 28, 2012, and June 10, 2012, due to dislodgement of the G-tube. On May 28, 2012, the resident was admitted to the GACH for four days (until June 1, 2012), during which time the resident?s G-tube site was noted closed and the resident underwent a G-tube replacement (May 29, 2012) via endoscopic surgery (endoscopic surgery uses a scope going through small incisions for minimally invasive surgery). On June 10, 2012, the resident was seen in the emergency room due to pulling the G-tube out again. According to the GACH emergency room?s record, the resident?s ? tube was replaced and the resident was transferred back to the facility the same day. An article written by the American Journal of Nursing (AJN) titled, ?Bedside Assessment of Enteral Tube Placement? dated February 2012, Vol.112, No.2, the severity of resulting complications depends on whether the mal-positioned tube has been used to deliver feedings or medications, but possible outcomes include aspiration, pneumothorax (a collapsed lung), and sepsis (a potentially life-threatening complication of an infection).The facility failed to:1. Provide appropriate care, treatment, and services for prevention of Resident 1?s G-tube being pulled out after the resident pulled it out twice within 14 days. 2. Follow the facility?s policy in obtaining a physician?s order for re-insertion of a G-tube. 3. Update the resident?s plan of care after the resident pulled out the G-tube on May 28, 2012, and again on June 10, 2012. The above violations either jointly, separately, or in any combination had a direct or immediate relationship to patient health, safety, or security. |
| 910000086 |
TORRANCE CARE CENTER EAST |
910009990 |
B |
02-Jul-13 |
J8EK11 |
12160 |
Code of Federal Regulations F224, F225, F226 ? Staff Treatment of Residents F224 and F226483.13 (c) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. F225 (1)(ii-iii), (c)(2)-(4) The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.On November 2, 2010, an entity reported incident (ERI) was investigated, in which a resident?s (Resident A), family member, alleged that an employee (Staff 1) choked Resident A with a towel, while giving him a shower, because he was being resistive to care. During the investigation it was determined the facility knew about the allegation, which was reported to them by Resident A on the day it occurred (September 28, 2010), however, the facility staff did not report the incident to the Department of Public Health (DPH) or investigate the allegation of abuse until October 4, 2010, (six days after the incident occurred) and allowed Staff 1 to continue caring for the resident for five days after the allegation was made. Based on interview and record review, the facility?s staff failed to: 1. Ensure the facility?s policy and procedure for ?Adult/Elder Abuse Reporting? was implemented. On September 28, 2010, Resident A reported to facility staff, that he was choked by an employee. The allegation of abuse was not investigated, reported to the DPH or the facility?s abuse coordinator (the administrator) until he returned to the facility on October 4, 2010, (six days after the incident occurred). The Resident?s responsible party was not notified of the incident, an assessment of the Resident to determine if he sustained any injuries was not completed and there was no written documentation regarding the allegation of abuse. Staff 1, who was accused of abuse by Resident A, continued providing care to the Resident for five additional days following the allegation and was not suspended, per facility policy. A review of Resident A's Admission Records indicated he was a 66-year old male, who was admitted to the facility on July 26, 2010, with diagnoses that included chronic low back pain and psychosis. According to a Minimum Data Set (MDS) Assessment, dated August 8, 2010, Resident A?s cognitive skills for daily decision-making were moderately impaired. His speech was unclear but he was able to make himself understood and understood others. He was assessed as resistive to care and required extensive assistance with personal hygiene and bathing. Licensed Personnel Progress Notes, dated September 28, 2010, at 2 p.m., indicated a call was placed to Resident A?s physician to report the resident hit a nurse in the head with a shower head but there was no written documentation of the resident?s accusation, physical assessment of the resident or notification of the incident to the resident?s responsible party. Licensed Personnel Progress Notes, dated October 22, 2010, at 7:15 a.m., indicated Resident A refused care, stating, ?I do not want you taking care of me, you might hurt me.? Per documentation, Resident A was noted to be holding his throat as if he were being choked. On November 2, 2010, at 8:40 a.m., the Surveyor attempted to interview Resident A. The resident was able to state his name and looked at the clock when asked if he knew the date and time, which indicated he was alert and oriented x3, but his speech was unclear. Resident A was asked about the incident in the shower room; he attempted to tell the story by gesturing and mumbling but was not understood.On November 2, 2010, at 9:25 a.m., during an interview, the Director of Nursing (DON) stated on October 4, 2010, she found out the police were at the facility on Sunday, October 3, 2010, because Resident A?s family member reported the incident to the police. The DON stated she had not spoken to the Resident?s family member or the accused employee (Staff 1). She stated on the day of the incident (September 28, 2010) Staff 1 reported to the director of staff development (DSD) that he had been hit by Resident A with a shower head. The DON stated on October 4, 2010, she and the social service designee (SSD) spoke to Resident A, who told them Staff 1 was being rough with him and that was why he hit him, and that was when Staff 1choked him with a shower blanket. On November 2, 2010, at 9:30 a.m., during an interview, the DSD stated she spoke to Resident A on the day of the incident (September 28, 2010). He told her Staff 1 choked him with a blanket. She stated she did not think to report the incident or follow up with an investigation because Resident A did not have any injuries.On November 2, 2010, at 9:33 a.m., during an interview, the administrator stated he was not at the facility when the incident occurred and was not made aware of it until he returned to the facility on October 4, 2010, (six days later). He stated when he was made aware of the incident; he reported the allegation to the DPH and suspended Staff 1. When asked about the investigation, the administrator could only produce a statement from Staff 1. He confirmed there was no written documentation from Staff 2, Staff 3 the DSD or the DON regarding the allegation of abuse. Social Progress Notes, dated October 4, 2010, at 12:50 p.m., indicated the physician was informed the police were in the facility on Sunday (October 3, 2010) looking for Staff 1. Per documentation the SSD spoke to Staff 1 who indicated during the previous week Resident A hit him on the head. The SSD along with the DON spoke to Resident A, who admitted hitting Staff 1 in the head because Staff 1 choked him. At that time (six days after the incident occurred) the administrator was informed of the resident?s allegation.A written statement by Staff 1, dated October 4, 2010, indicated after giving the resident a shower, he was standing behind him attempting to put a cover on him. The resident took the hose of the shower head and hit him on his head. The resident then tried to get up from the chair and Staff 1 pushed him back to prevent the Resident from falling from the chair. He reported the incident to the team leader and the charge nurse. On April 12, 2012, at 2:15 p.m., during a telephone interview, Staff 2 stated Staff 1 reported to her that Resident A hit him on his head with a shower head. She and the DSD went to the resident because they wanted to get both sides of the story. Staff 2 stated she did not recall what the resident said and they should have documented the interview. On April 12, 2012, at 2:20 p.m., during a telephone interview, Staff 3 stated Staff 1 came out of the shower room saying Resident 1 was swinging a shower head and hit him with it. Staff 3 stated he accompanied Staff 2 back to the shower room to assist him with completing the resident?s care. He stated he probably did ask the resident what happened but did not remember what his response was. There was no documentation of the incident. On April 12, 2012, at 2:45 p.m., during a telephone interview, Staff 1 stated Resident A became agitated, while he was giving him a shower. The resident grabbed the shower hose from him and hit him in the head with it. Staff 1 stated Resident A looked as though he was trying to get up from the shower chair and he was afraid the resident would fall so he grabbed his shower blanket and pulled him back. Staff 1 stated Resident A may have thought he was trying to choke him but he was trying to prevent him from falling. Staff 1 stated when Staff 3 came towards the shower room he told him what happened and asked for assistance. Once they got the resident to his room he reported the incident to Staff 2.A Daily Nursing Sign-In Sheet indicated Staff 1 was assigned to Resident A on September 28, 2010, (the day the incident occurred) and continued to be assigned to Resident A the remainder of September 28, the 29-30 and October 1, 3-4 2010, six days after the resident accused Staff 1 of choking him.A facility policy and procedures on Adult/Elder Abuse Reporting, (not dated) indicated the basic responsibility of every employee is to ensure the safety and well-being of residents. Abuse must be reported if the elderly person tells a mandated reporter that he/she suffered abuse. The facility will assure that alleged violations are reported immediately to the department head or to the administrator. Any elder care custodian, medical practitioner or employee of an elder protective agency who has actual knowledge that an elder has been a victim of any type of abuse shall report the suspected abuse by telephone to the department of licensing and certification and the local long term care ombudsman, immediately or as soon as practically possible and shall prepare and send a written report within (5) days. Any person having information of any suspected act that he/she considers may be abuse, is responsible for: Immediately reporting the information directly to the individual?s department head or the administrator regardless of the time of the day, immediately reporting any observed or suspected case of resident physical abuse to the department of health services and to the local long term care ombudsman coordinator. Whenever an allegation of resident abuse is received from any source, an immediate investigation is made by the department head and the administrator is informed. The clinical record of any resident for whom a suspected abuse/abuse report is completed must contain objective information/facts not speculation. If it is not clear what occurred, an investigation should be implemented to assure prevention of the same type of event. After a physical and mental assessment of the resident; document the date, time and location of the alleged incident. A complete description of the event, including whether it was an isolated event or an ongoing situation, physical findings on examination, and to whom the event was reported; the sequence of the event; any comments by the injured person regarding the name of the person suspected of inflicting the injury; a complete description of any injuries sustained, including site, size, appearance, presence/absence of pain and if there is pain, a complete description including level of pain, whether a staff member was involved, interventions to calm/reassure the resident; update of the care plan by the interdisciplinary team with preventive measures as appropriate and notification of the resident?s family. A suspected employee is removed immediately from care of the resident and suspended pending the outcome of the investigation. Therefore the facility?s nursing staff failed to: 1. Ensure the facility?s policy and procedure for ?Adult/Elder Abuse Reporting? was implemented.This violation had a direct relationship to the health, safety, or security of Resident A. |
| 910000091 |
TORRANCE CARE CENTER WEST, INC. |
910010439 |
A |
07-Feb-14 |
F5T511 |
9976 |
F 223 483.13(b) Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The Department received a faxed allegation of abuse on October 28, 2010, alleging a certified nursing assistant (CNA 1) was seen on a video abusing a resident (Resident 1). According to the complaint the resident?s family had become suspicious of many unexplained bruises on Resident 1 and installed a hidden camera in the resident?s room. The police were notified and observed the video of CNA 1 hitting Resident 1 while rendering care to him.On November 12, 2010, an unannounced visit was conducted to investigate the complaint.Based on interview and record review, the facility failed to ensure Resident 1 was free from abuse, by allowing CNA 1 to continue to provide care for Resident 1 after being suspended in 2006 for verbally abusing the same resident.This failure resulted in Resident 1, who was non-English speaking, had minimal speech, and required total assistance with care, being verbally and physically abused and required a transfer to a general acute care hospital (GACH) for a physical abuse evaluation. The GACH kept the resident for a 23-hour observation to remove him from harm and to find new placement. On November 12, 2010, at 3 p.m., during an interview, the facility?s administrator stated CNA 1 was arrested for physically abusing Resident 1. The administrator also stated the day before the arrest the resident?s son had the resident transferred to a GACH. The administrator stated he was not aware of the alleged physical abuse until the resident?s family reported it to the police and the police came to the facility. The administrator stated, ?He (CNA 1) seemed like a team player.? In the CNA?s employee file was an Employee Code of Conduct, dated and signed by CNA 1 on August 5, 2006, which indicated violation of any of the following acts would constitute cause for TERMINATION: violation of resident?s rights, arguing, fighting, or threats of any nature to any staff or resident. A review of CNA 1?s employee file indicated the he was hired at the facility in August 2006. A review of the facility?s ?Nursing Daily Sign-in Sheets? for various days in October 2010, revealed documentation that CNA 1 was a team leader for the facility?s CNAs. A review of a written reprimand, dated March 26, 2010, indicated CNA 1 was written up for violating the facility?s policy and procedure from March 1-15, 2010, by coming to work late without calling after being verbally counseled.A review of Resident 1's clinical record indicated he was a 62 year-old male initially admitted to the facility in 2005 and last re-admitted on August 10, 2010. His diagnoses included cerebral vascular accident [(CVA) sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain; also referred to as a stroke] with right-sided hemiplegia (total or partial paralysis of one side of the body) and aphasia (partial or total loss of the ability to articulate ideas or comprehend spoken or written language), dementia (loss of mental functions such as thinking, memory, and reasoning that is severe enough to interfere with a person's daily functioning) and seizure disorder (any condition in which there are repeated episodes of seizures of any type). A review of a weekly summary for Resident 1, dated September 3, 2010, indicated the resident was non-verbal to all stimuli, non-ambulatory and relied on a wheelchair for mobility, was incontinent (inability to control) of both bowel and bladder, and required limited to extensive assistance with all activities of daily living. The summary also indicated the resident had good family support, who visited frequently and was involved in the resident?s care. A review of a Transfer Record, dated August 8, 2010, indicated the resident experienced right-sided weakness and was transferred to a GACH for further evaluation per the physician?s orders. A review of the GACH?s History and Physical (H/P) for Resident 1 indicated the resident had an abrasion on the left side of his forehead and left parietal scalp swelling. A Computed tomography [(CT) scan that produces multiple images or pictures] of the resident?s brain was negative. A review of a telephone physician?s order, dated October 19, 2010, and timed at 12:30 p.m., indicated, ?For transfer to hospital ER for evaluation as per family?s request.? A review of the GACH?s history and physical (H/P), dated October 20, 2010, indicated the resident was transferred to the emergency room (ER) for a 23-hour observation. The H/P also indicated the resident?s family member was urged to remove the resident from the skilled nursing facility (SNF) by the police due to suspected elder physical abuse. Under diagnoses, elder abuse warranting transfer was listed as the number one reason for transfer. On October 20, 2010, Resident 1 was discharged by the GACH to another SNF. A review of a Social Work Psychological Assessment, dated October 19, 2010, indicated the resident had discoloration to his right shoulder, and a picture was taken in the ER of the discoloration. On November 23, 2010, at 10 a.m., during a telephone interview, Resident 1?s family member, who visited him frequently and was very active in the resident?s care, stated three to four years prior, CNA 1 was suspended for a week for verbally abusing Resident 1 and was made to apologize. The family member stated in recent months the resident had many un-explained bruises all over his body and the resident started acting differently. Resident 1?s family member stated another resident (unidentified) told him a month prior that CNA 1 was rough with him as well. The family member stated he did not know the other resident by name, but by face only. The family member stated he would report his concerns to the facility?s staff, but would not get any answers, so he installed a hidden camera in Resident 1's room. The family member stated when he viewed the video, he saw CNA 1 hitting and slapping Resident 1. He stated he did not inform the facility, but took the video to the police station immediately. The family member stated he called the resident?s physician and had him give an order to transfer the resident to the hospital for safety, as was suggested by the police. A review of a police ?General Case Report? dated October 20, 2010, indicated an incident of suspected elder abuse was reported to have occurred on October 19, 2010, at 4:22 a.m., the victim being Resident 1 and the perpetrator being CNA 1. The case status indicated CNA 1 was arrested on October 20, 2010, at 11:15 a.m. According to the police ?Crime Report,? dated December 3, 2010, Resident 1?s family member walked into the resident?s room in 2006 and witnessed CNA 1 cursing at the resident regarding his food. The family member informed the facility and CNA 1 was placed on suspension, but was allowed to return to work. The family member stated he had no further problems with CNA 1 until recent months, after the resident was seen with a four inch neck laceration on the right side of the neck on May 15, 2010, and a bruised left eye with swelling on August 17, 2010. The family member questioned the facility, but was told the resident had fallen.The family member then set up a hidden video camera in the resident?s room from October 17- 18, 2010. The video was brought to the Police Department and they (police) indicated CNA 1 was observed in the resident?s room putting the resident?s clothes on him in what appeared to be a forceful manner. In the video, according to the report, CNA 1 was observed striking Resident 1 in the face with what appeared to be a closed right fist, and moments later CNA 1 was observed striking the resident again, with an opened right hand. A review of the typed police investigation report, which was recorded, indicated CNA 1 was interviewed by the police at the facility on October 20, 2010. According to the report, CNA 1 stated he became frustrated with the resident, which caused him to hit the resident on the face multiple times. During the interview, CNA 1 admitted to the police officer he was suspended from the facility in 2006 for cursing at the same resident.A review of a ?Los Angeles County Booking/Property Record? dated, October 20, 2010 , and timed at 11:15 a.m., indicated CNA 1 was arrested and booked for elder/dependent adult cruelty (PC368 C). A review of the ?Minute Order for the Superior Court of California? dated May 16, 2011, indicated the defendant (CNA 1) was charged with four counts of abuse against Resident 1. According to the Minutes, CNA 1 withdrew his plea of not guilty and the court found him guilty and convicted him of Count 1. A review of the facility?s abuse policy, titled, ?Adult/Elder Abuse Reporting Policy & Procedures? indicated the facility fully protected the rights of the individual for whom they provided care. In addition, any form of abuse and neglect would not be tolerated. The policy also indicated they would enforce the principles of resident?s rights by non-tolerance of verbal, sexual, physical, mental and financial abuse. However, CNA 1 was allowed to continue to work and care for Resident 1 at the facility, after he was observed to verbally abuse the resident.The facility failed to ensure Resident 1 was free from abuse, by allowing CNA 1 to continue to provide care for Resident 1 after being suspended in 2006 for verbally abusing the same resident.This failure resulted in Resident 1 being verbally and physically abused and required a transfer to a GACH for a physical abuse evaluation. The GACH kept the resident for a 23-hour observation to remove him from harm and to find new placement. This violation presented either imminent danger or serious harm would result or a substantial probability that death or serious physical harm would result to Resident 1. |
| 910000336 |
The Rehabilitation Center of Santa Monica |
910010581 |
A |
22-Apr-14 |
4YPI11 |
10903 |
Class A CitationCalifornia Code of Regulations Title 22 Nursing Service ? Administration of Medications and Treatments Section 72313(a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. An unannounced complaint investigation was conducted on August 30, 2011 at 3 p.m., regarding an allegation that Patient 1 died after not receiving the correct dosage of blood pressure medications. Based on interview and record review, the facility failed to administer medications as prescribed by failing to: Ensure that a patient whose diagnoses included hypertension (HTN [high blood pressure]), atrial fibrillation (irregular heart beat), and cardiovascular disease (disease affecting the heart or blood vessels) received Cardizem (to treat high blood pressure and to control angina [chest pain]) 120 milligrams (mg) and Metoprolol (used to treat angina and hypertension) 25 mg twice a day from August 11 to 15, 2011, as prescribed by Patient 1?s physician.The failure to administer the medication as prescribed by the physician resulted in Resident 1 having decreased heart efficiency that decreased the blood supplied to the brain and heart. This was seen by the falling oxygen saturation reading. The heart was struggling to deliver blood oxygen to the brain and heart as needed. The patient had a cerebrovascular accident (lack of blood to the brain) from hypertension.On August 15, 2011 at 10:30 a.m. during physical therapy treatment, Patient 1 became diaphoretic (sweating profusely), pale, and complained of not feeling well. Patient 1?s blood pressure was 153/94 milliliter mercury (mmHg) (normal systolic pressure is the blood pressure when the heart muscle contracts) range from 120 to 134, normal diastolic (pressure is the blood pressure when the heart is relaxed) range from 70 to 85), heart rate 150 to 180 beat per minute (bpm) (normal range 60 to 80 bpm), the oxygen saturation reading was 78 to 89 percent (normal range 97 to 99 percent) and Patient 1 had labored (difficulty) breathing, oxygen 6 liter per minute was administered.At 11:35 a.m., the patient became diaphoretic again, and had a very faint pulse, vital signs were not detectable and the patient became unresponsive, and cardiopulmonary resuscitation (CPR [a procedure designed to restore normal breathing after cardiac arrest]) was started. The paramedics were called and Patient 1 was transferred to a general acute care hospital (GACH), and was pronounced dead at 12:46 p.m. The admission record indicated Patient 1 was an 88 year-old male admitted from a GACH to the facility on August 11, 2011, at 5:17 p.m., with diagnoses that included atrial fibrillation, cardiovascular disease, coronary artery disease (a narrowing of the small blood vessels that supply blood and oxygen to the heart), and hypertension.The Physician Orders for Life-Sustaining Treatment (POLST) dated August 12, 2011, indicated Patient 1 requested ?CPR and Full Treatment.?The physician?s order dated August 11, 2011 at 6 p.m., indicated to administer Cardizem 120 mg and Metoprolol 25 mg by mouth, twice a day (9 a.m., and 9 p.m.). Hold if the systolic blood pressure is less than 100 mmHg or heart rate less than 50 beats per minute for hypertension.A care plan initiated on August 11, 2011, for diagnosis of hypertension, included the intervention to administer medications as ordered: Cardizem 120 mg and Metoprolol 25 mg twice a day.The Medication Administration Record (MAR) from GACH indicated Patient 1 last received his Cardizem 120 mg and Metoprolol 25 mg on August 11, 2011 at 9 a.m.The facility?s MAR, dated August 11, 2011 through August 15, 2011 at 9 a.m. reflected that Patient 1 received the Cardizem and Metoprolol medications as ordered by the physician, except in the evening of August 11, 2011, when Patient 1 was admitted.Patient 1?s blood pressure and heart rate monitoring indicated the following: 1. August 11, 2011, at 9 p.m., there were no vital signs recorded. 2. August 12, 2011, at 9 a.m., the Blood Pressure (BP) reading was 68/87, the heart rate was 98 bpm, at 9 p.m. BP 132/76 and the heart rate was 96 bpm. 3. August 13, 2011, at 9 a.m. the BP reading was 133/67, the heart rate was 101 bpm, at 9 p.m., the BP reading was 115/70 and the heart rate 98 bpm. 4. August 14, 2011, at 9 a.m. ,the BP reading was 133/67, the heart rate was 97 bpm and at 9 p.m., BP was 133/67 and the heart rate was 97 bpm. 5. August 15, 2011, at 9 a.m., the BP reading was 114/88, and the heart rate was 105 bpmThe Nurse?s Notes, dated August 15, 2011 at 10:30 a.m. indicated during the physical therapy treatment, Patient 1 became diaphoretic, pale, and was complaining of not feeling well, blood pressure reading was 153/94 milliliter mercury (mmHg), heart rate 150 to 180 bpm, oxygen saturation reading was 78 to 89 percent, and the patient had labored breathing. Oxygen was administered at 6 liter per minute. The physician was notified of Patient 1?s condition, with no new orders. At 11 a.m. the Nurse?s Notes indicated the patient was reassessed, and the blood pressure reading was 112/76, heart rate 82 bpm, respiratory rate 22 breaths per minute and oxygen saturation reading was 91 to 92 percent. At 11:35 a.m., the Nurse?s Notes indicated the patient became diaphoretic again, with very faint pulse and vital signs cannot appreciate. The nurse tried to contact the physician, and by that time the faint pulse was gone, 911 were called and CPR was started.The Emergency Medical Services Report Form, dated August 15, 2011, indicated dispatch time 12:02 p.m., at scene 12:05 p.m., at patient 12:06 p.m. at 12:07 p.m. the BP reading was 0/0, pulse 30 bpm and respiration 4 breaths per minute (bpm).At 12:12 p.m. BP 0/0, pulse 30 bpm and respiration 4 bpm. At 12:17 p.m., BP 0/0, pulse 0 (zero), and respiration 0 (zero). At 12:20 p.m. BP 0/0, pulse 0 (zero), and respiration 0 (zero). The paramedics left the facility to GACH at 12:29 p.m. The GACH Emergency Medicine Summary, dated August 11, 2011, indicated upon arrival to the GACH Emergency Room Patient 1?s heart rhythm was asystole (absence of any heartbeat). There was no change in the Patient 1?s heart rhythm after continuous CPR.Patient 1 was pronounced dead at 12:46 p.m. The Death Certificate indicated Patient 1?s immediate cause of death was cerebrovascular accident and hypertension The facility's investigation Interview Record indicated the day shift licensed vocational nurse (LVN 1) did not administer the Cardizem and Metoprolol on August 12, 2011 at 9 a.m. LVN 1 borrowed Cardizem 60 mg (half of the dosage the physician ordered) on August 13, and 14, 2011, at 9 a.m., from Patient 2, and gave the medication to Patient 1. The interview record indicated LVN 1 administered the Metoprolol 25 mg on August 13, 2011, at 9 a.m. because the pharmacy delivered the medication.The facility's investigation Interview Record indicated LVN 2, evening shift licensed nurse did not administer the Cardizem 120 mg and Metoprolol 25 mg on August 11, 2011, the night Patient 1 was admitted. The interview record indicated LVN 2 was off on August 12 and 13, 2011 and on August 14, 2011 she borrowed Cardizem 60 mg (half of the dosage the physician ordered) from Patient 2 and gave the medication to Patient 1. The Interview Record indicated LVN 2 administered Metoprolol 25 mg on August 14, 2011, at 9 p.m.The facility?s investigation Interview Record indicated registered nurse (RN 1) was asked if she knew that Patient 1 was not receiving the medication because the pharmacy did not deliver it. RN 1 stated she found out only on August 15, 2011 at 7 a.m. when the resident was having a change of condition.During an interview with LVN 3 on October 25, 2011 at 11:20 a.m., he stated on August 12 and 13, 2011 at 9 p.m, he borrowed Cardizem 120 mg from Patient 2 and gave the medication to Patient 1. LVN 3 stated he did not give the Metoprolol 25 mg until August 13, 2011. A review of Patient 2?s recapitulation of Physician Orders for the month of August 2011 indicated the following hypertension medications: 1. Amlodipine Besylate (Norvasc) 10 mg one tablet every day. 2. Diltiazem 30 mg one tablet four times a day 3. Hydralazine Hydrochloride (Apresoline) to take 1.5 tablets (75 mg every eight hours. Patient 2 was not prescribed Metoprolol in August 2011, therefore the evening shift nurse could not have borrowed Metoprolol from Patient 2 and give it to Patient 1. Review of the Pharmacy Delivery Receipt indicated the Metoprolol was delivered to the facility on August 13, 2011, at 5:32 p.m; the Cardizem was still not available.On October 25, 2011 at 2 p.m., after the administrator conducted his investigation he stated the Cardizem 120 mg was not given on August 11, 13, and 14, 2011, at 9 p.m. and August 12, 2011, at 9 a.m., and Cardizem 60 mg (half of the dosage the physician ordered) was given on August 12 and 13, 2011, at 9 a.m. The administrator stated the Metoprolol 25 mg was not given to Patient 1 on August 11, 2011, the night he was admitted to the facility. The administrator also confirmed Patient 1 did not receive the Metoprolol 25 mg on August 12 and 13, 2011, at 9 a.m. and 5 p.m. because the medication was not available as Patient 2 had no order for Metoprolol. The facility's policy and procedures for Unavailable Medications, dated December 18, 2006, indicated the nurse should have arranged for an emergency delivery, the medication should have been obtained from the emergency supply stock, notified the physician, notified the nursing supervision and contacted the medical director. The facility nurse should have documented the missed dose and explained why the medication was not given, however none of these steps were taken according to the policy. The facility failed to administer medications as prescribed by failing to: Ensure that a patient whose diagnoses included hypertension (HTN [high blood pressure]), atrial fibrillation (irregular heart beat), and cardiovascular disease (disease affecting the heart or blood vessels) received Cardizem (to treat high blood pressure and to control angina [chest pain]) 120 milligrams (mg) and Metoprolol (used to treat angina and hypertension) 25 mg twice a day from August 11 to 15, 2011, as prescribed by Patient 1?s physician.This failure to administer the medication as prescribed by the physician resulted in Resident 1 having decreased heart efficiency that decreased the blood supplied to the brain and heart. This was seen by the falling oxygen saturation reading. The heart was struggling to deliver blood oxygen to the brain and heart as needed. This resulted in a cerebrovascular accident (lack of blood to the brain) from hypertension.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. |
| 910000086 |
TORRANCE CARE CENTER EAST |
910010666 |
B |
25-Apr-14 |
CZ6711 |
5078 |
F204 42 CFR 483.12(a)(7) Orientation for transfer or Discharge A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. F 205 42 CFR 483.12 (b) Notice of Bed-Hold Policy and Readmission 42 CFR 483.12 (b) (1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies-- (i) The duration of the bed-hold policy under the State plan, if any, during which the residents 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. A complaint investigation regarding an inappropriate transfer/discharge (T/D) was conducted on November 22, 2013.Based on interview and record review, the facility failed to: 1. Ensure that Resident A and/or family member or legal representative had been provided with a written notice of a bed-hold before the resident was transferred to a general acute care hospital (GACH). 2. Ensure Resident A was notified and provided with sufficient preparation before the resident was transferred from Facility A to Facility B on November 20, 2013.During an interview with Resident A, on November 22, 2013 at 7:30 a.m., he said on November 20, 2013, he did not know the time he was transferred by a van from the GACH back to the skilled nursing facility ([SNF] Facility A). However, when he arrived at Facility A he was placed into another van and then taken to Facility B.Resident A, a 51-year-old male, was admitted to Facility A on January 6, 2010, with diagnoses that included atherosclerotic heart disease (plaque buildup inside arteries), hypertension (high blood pressure), diabetes mellitus (high blood sugar) , and psychosis (loss of contact with reality).The Minimum Data Set, a standardized assessment and care screening tool, dated October 23, 2013, indicated the resident?s cognition skills were intact, and the resident required supervision with activities of daily living.According to a review of the Licensed Personnel Progress Notes, dated November 15, 2013 at 11 a.m., the licensed nurse documented the resident attacked a staff member with a closed fist. The resident was agitated and staff was unable to redirect the resident. The attending physician was called and the physician ordered the resident to be transferred to the GACH for evaluation. At 11:45 a.m., the resident was transferred to the GACH accompanied by two emergency medical technicians. The resident was admitted to the GACH for evaluation. There was no documented evidence the resident and/or family member was given a written notice of a bed-hold. A review of the Discharge Summary from the GACH, dated November 20, 2013, indicated Resident A was discharged back to Facility A. During an interview with the director of nurses at Facility A, on November 22, 2013 at 9:35 a.m., she said she left a message on the discharge planner?s answering machine stating the resident is to be transferred to Facility B.Resident A?s medical records were reviewed and there was no documentation to indicate the resident and the resident?s family member had been notified and were provided sufficient preparation before the resident was transferred to Facility B. A review of the Face Sheet from Facility B indicated the resident was admitted to the facility on November 20, 2013 at 5:20 p.m. According to a review of the Daily and Every Shift Charting, dated November 20, 2013 at 5:20 p.m., the licensed nurse documented the resident was admitted from Facility A accompanied by staff from Facility A.During an interview with the case manager/risk manager at the GACH, on November 25, 2013 at 9:45 a.m., she said the resident?s transfer was delayed on November 19, 2013, because Facility A declined the resident (four days after the resident was transferred to the GACH). On November 20, 2013, she stated she was informed by Facility A that Resident A?s bed was available the afternoon the resident was transferred to Facility A.The facility failed to: 1. Ensure Resident A and/or family member or legal representative had been provided a written notice of a bed-hold before the resident was transferred to general acute care hospital (GACH).2. Ensure Resident A was notified and provided with sufficient preparation before the resident was transferred from Facility A to Facility B on November 20, 2013.The above violation has a direct relationship to the health safety or security of patients. |
| 910000036 |
THE EARLWOOD |
910010728 |
B |
13-May-14 |
ZZMG11 |
3675 |
CFR 483.13(c)Staff Treatment of ResidentsF224 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. On December 11, 2012 at 10:00 a.m. an unannounced visit was made to the facility to conduct an entity reported investigation. Based on observation, interview and record review, the facility failed to: 1. Implement the facility policy and procedures that prohibit misappropriation of resident property.Resident A?s checks were stolen and cashed while he was a resident in the facility. A review of medical record indicated Resident A was a seventy-six year old male readmitted to the facility on April 7, 2011, with diagnoses that included open wound site, atrial fibrillation, and fracture tibia with fibula-close, diabetes mellitus without complication, anemia, and dementia without behavior. The Minimum Data Set Assessment (a tool for nursing home resident assessment and care screening) dated October 10, 2012, indicated that Resident A was cognitively intact. On December 11, 2012 at 10:30 a.m. Employee 1 stated during an interview, she was informed by the director of nursing and the administrator that the resident had reported to them he was missing two checks. Employee 1 stated she filled out the Report of Suspected Dependent Adult/Elder Abuse, form, and faxed the form to the Department of Public Health, Ombudsman office and called the police. She stated that she did not actually talk to the Patient about the incident because he refused to talk to her about anything. On December 12, 2012 at 11:37 a.m. during an interview Employee 4, stated she was informed on November 19, 2012 about the missing checks and was given Resident A?s checkbook for safe-keeping. On December 12, 2012, during an interview with Resident A, he stated he kept his check book in a drawer by his beside. He further stated, he called his bank to get his checking account balance and discovered two checks had been cashed from his checking account.He stated he requested copies of the checks from his bank and then gave his checkbook to Employee 2 for safe-keeping.A review of Employee 2?spersonnel record revealed the employee was terminated for not following the employee code of conduct she signed on July 7, 2011, because she failed to report the allegation of abuse. A review of the facility?s investigative file produced a photocopy of the two checks with Resident A?s name on them and his home address. One check was dated October 23, 2012, for $200.00. And the other check was dated October 28, 2012, for $200.00. One check was cashed on October 26, 2012 and the other check was cashed on October 30, 2012. The two checks were written to employee 3 and cashed using finger prints on the front of the check and employee 3?s signature on the back of the checks. On December 11, 2011, during an interview with Resident A regarding the two checks, the patient stated that he did not write the check to Employee 3. He stated he had informed his bank that he did not write the two checks to Employee 3. A review of a facility?s abuse manual given to Employee 3 (perpetrator) upon hiring, revealed financial abuse was covered in the text. Employee 3 had received abuse training on March 10, 2011, as evidenced by her signature on the abuse training certification form. The failure of the facility to implement the facility policy and procedures that prohibit misappropriation of resident property, resulting in Resident A?s checks being stolen and cashed while he was in the facility, had a direct relationship to the health, and safety and security of Resident A. |
| 910000036 |
THE EARLWOOD |
910011598 |
A |
21-Jul-15 |
L0HS11 |
13834 |
42 CFR 483.25(h)The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.Based on observation, interview and record review the facility failed to maintain a hazard free environment for Resident 1, who had muscle weakness and hemiplegia (paralysis of one side of the body that results from disease or injury) and was unable to bear weight. The facility failed to: 1. Provide two-person physical assistance during Resident 1's transfer from a wheelchair to a bed by using a Sabina II EE mechanical lift (a mechanical device used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually).2. Assess Resident 1 to determine lifting equipment and transfer needs in accordance with the facility's policy and procedure. 3. Follow the facility's policy and procedure for the use of mechanical lifts which required at least two persons to be present while a resident was transferred with the mechanical lift. 4. To train licensed nurses and a certified nursing assistants (CNAs) on use of Sabina II EE mechanical lift and selection of lifting accessories to ensure safe transfer.These deficient practices resulted in Resident 1 sustaining a fracture of the left humerous, (upper arm) and left forearm with soft tissue swelling, to experience unbearable pain and to be admitted to a general acute care hospital (GACH) for two days.On January 22, 2015 at 2:30 p.m., an unannounced visit was conducted to investigate an Entity Reported Incident (ERI) about Resident 1's fall during the transfer process from a wheelchair to a bed with mechanical lift on January 9, 2015. The resident slipped from the Support Vest sling with the lower half of the body on the floor and the resident's left arm was caught in the sling while CNA 1 was lifting the resident with a mechanical lift without any assistance. According to Resident 1's admission record, the resident was originally admitted to the facility on January 15, 2010, with diagnoses which included rheumatoid arthritis (a disease which affects the lining of joints, causing a painful swelling that can eventually result in bone and joint deformity), systemic lupus erythematosus (an autoimmune disease in which the body's immune system mistakenly attacks health tissue. It can affect the skin, joints, kidneys, brain, and other organs) and re-admitted on January 15, 2015, with diagnosis of a fracture of a left upper arm. A review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated January 22, 2014, indicated Resident 1 had severely impaired cognitive skills for daily decision-making and required extensive assistance with bed mobility, dressing, eating, toilet use, personal hygiene and transfer between surfaces including to or from bed, chair, wheelchair and standing position. According to the MDS, Resident 1 required two plus persons physical assistance with aforementioned activities of daily living (ADL) and was totally dependent on staff for locomotion on and off unit and bathing. Also, MDS indicated Resident 1 had a functional impairment of a left upper and lower extremity. During an interview conducted on January 22, 2015 at 2:30 p.m., with the facility's Administrator, Director of Nurses (DON) and the Director of Physical Therapy (PT), they stated CNA 1 was terminated on January 14, 2015, and was not available for interview. A review of the facility's post fall investigative report dated January 9, 2015, indicated that on January 9, 2015, at approximately 2 p.m., CNA 1 went to Resident 1's room where the resident was sitting in a wheelchair. CNA 1 left the room to bring the Sabina II EE lift (a mechanical device used to lift and transfer residents from a seated position to the bed) to transfer Resident 1 from the wheelchair to the bed. In the process of transferring Resident 1 began to fall through the sling. CNA 1 then stopped the operation of the Sabina II EE lift; however, Resident 1 continued to fall and ended up sitting on the floor while the resident's left arm was caught in the sling bearing the resident's weight. CNA 1 immediately grabs Resident 1, lifts the resident up and put the resident on the bed. CNA 1 went out of the room and notified the charge nurse licensed vocation nurse 1 (LVN 1). According to Situation Background Assessment Request (SBAR) dated January 9, 2015, the LVN 1 found Resident 1 groaning and lying in bed with the head of the bed elevated. The LVN 1 documented Resident 1 had swelling on the left shoulder and groaned louder when the shoulder was touched. LVN 1 asked Resident 1 where was the pain and the resident pointed to her left shoulder and left hand. Resident 1 indicated the pain to the left shoulder was a ten on scale from zero to ten, where a zero was no pain and ten was the most unbearable pain. According to Resident 1's Post Fall Report, dated January 9, 2015, Resident 1 confirmed she had a fall. The report documented the physician was notified of the fall on January 9, 2015 at 2:20 p.m., and the resident was given 500 milligrams Vicodin, (a narcotic analgesic medication) for pain in her left arm. Resident 1 was then transferred by ambulance to the acute care hospital emergency room. A review of the acute hospital's physician progress notes dated January 13, 2015, indicated Resident 1 was admitted to the hospital on January 9, 2015, with intractable pain (a severe, constant pain that is not curable by any known mean, which causes a bed or house-bound state and early death if not adequately treated), of a left shoulder. According to the resident's History of Present Illness documented in the hospital's record and dated January 9, 2015, Resident 1 was on a mechanical lift during transfer, slipped and fell on her left side which was functionally impaired. According to the documented hospital's Review of the Systems, dated January 9, 2015, Resident 1's left shoulder was tender and deformed. According to the hospital physician's note, dated January 11, 2015, the recommendation was to apply the sling for immobilization without operative treatment, repeat an x-ray in the next one to two weeks and remain non-weight bearing on the left arm. During an interview on January 28, 2015 at 3:15 p.m., the PT stated that Resident 1 was totally dependent on facility's staff for transfer, including a transfer from a wheelchair to a bed. The PT additionally indicated the word "totally dependent" meant the resident required two or more staff to provide physical assistance for transfers. PT stated whenever a resident requires two plus persons physical assistance in transferring a Hoyer lift (a manual mechanical device that uses hydraulics to enable to lift/transfer a person between surfaces) is used. The PT was asked if he was aware that during the time of Resident 1's fall a Hoyer lift was not used to transfer Resident 1 from a wheelchair to a bed. The PT stated that he was aware that a Sabina II EE lift was used during Resident 1's fall on January 9, 2015, and added that the Sabina II EE lift is only used for partially dependent residents for transfer. The PT stated that at the completion of physical therapy treatment provided from May 21, 2014, to June 17, 2014, licensed nurses were provided with an assessment of Resident 1's functional abilities. A review of the PT's Evaluation and Plan of Treatment dated June 23, 2014, from May 21, 2014, to June 16, 2014, indicated Resident 1 was totally dependent in bed mobility, transfers, had impaired range of motion (ROM) for left lower extremity (LLE) and poor balance with support while sitting. A review of the facility's policy titled, "Mechanical Lift" (undated) indicated at least two people had to be present while the resident is being transferred with the mechanical lift. According to the facility's policy and procedure titled, "Lifting and Transferring of Resident," (undated) the licensed nurses had to assess and determine lifting and transfer requirement for each resident by assessing the resident for: a) Physical limitations. b) Equipment that must be moved. c) Ability of resident to follow directions. According to the policy, all residents should be lifted or transferred according to the assessment. All members of the nursing staff, licensed nurses and nursing assistants were responsible to know the procedures to operate assistive devices. Mechanical lift procedures were required to be used on any resident who was unable to independently pivot or transfer. A review of the resident's clinical record indicated there was a plan of care dated May 20, 2014, for impaired physical mobility manifested by total assistance with transferring. The intervention was to evaluate and provide appropriate devices and assistance. During a phone interview with the director of staff development (DSD) on March 25, 2105 at 1:40 p.m., DSD stated that the assessment is being done by the rehabilitation department including the assessment and determination of the physical limitations and selection of a proper mechanical lift that must be used to move the resident safely. The DSD confirmed there was no documented evidence in Resident 1's record to indicate the evaluation, determination, and mechanical lift selection was done as stated in the facility's policy and procedure. The DSD did not explain how the determination is made for the type of mechanical lift is selected for residents who require physical assistance with transfer and mobility between surfaces. On January 27, 2015 at 2:30 p.m., in the presence of administrator, observation occurred that the Sabina II EE mechanical lift used to lift Resident 1 had a "Narrow Sling Bar" with a Support Vest. Based on the nursing and PT's assessment as well as the manufacturer's recommendation, the Comfort Sling bar in combination with the Comfort Vest was for residents who were paralyzed on one side (hemiplegics). A review of manufacturer's instruction guide dated April 17, 2012, for the Sabina II EE lift indicated the Comfort Vest with a Comfort Sling bar were for someone who was paralyzed on one side and the Support Vest with the Narrow Sling bar were for the residents who were able to stand steadily. Personnel who were using the lift required training on the correct operation and use of the lift. The lifting accessory had to be selected appropriately in terms of type, size, material and design with regard to the resident's needs. The lifting accessory had to be correctly and safely applied on the resident in order to avoid bodily injury. A caregiver need to assure that the resident was not at risk of falling forward or to either side during lifting. A review of Resident 1's care plan dated May 20, 2014, for impaired physical mobility, indicated there was no documentation what mechanical lift and what lifting accessory would be used for Resident 1's transfer with the mechanical lift.According to the Sabina II EE lift manufacturer's product description dated April 17, 2012, a resident must be able to actively participate in the rising motion. The resident's overall mobility determines the choice of a sling bar and a sit-to-stand vest utilized during transfer.A review of the facility's policy and procedure titled, "Lifting and Transferring of Resident," indicated there was no documented evidence that would distinguish when a Hoyer lift is used or when the Sabina II EE lift is used. During an interview with the Administrator, DON and PT on January 28, 2015, at 3:40 p.m., they stated that manufacturer's recommendations for the use of the Sabina II EE lift were unfamiliar to the facility staff. They were unable to provide evidence that indicated in-service training was provided to direct care staff and licensed nurses on selection and use of mechanical lifts and their lifting accessories in accordance with manufacturer's recommendations. During an interview with the administrator, DON and PT on January 28, 2015 at 4 p.m., they stated that the facility had no policy and procedure for the use and application of the Support vest and Comfort vest. In addition, they stated the facility had not adopted the manufacturer's requirements for the use of the vests. The facility failed to maintain a hazard free environment for Resident 1, who had a muscle weakness and hemiplegia (paralysis of one side of the body that results from disease or injury) and was unable to bear weight. The facility failed to: 1. Provide two-person physical assistance during Resident 1's transfer from a wheelchair to a bed by using a Sabina II EE mechanical lift (a mechanical device used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually).2. Assess Resident 1 to determine lifting equipment and transfer needs for Resident 1 in accordance with the facility's policy and procedure. 3. Follow the facility's policy and procedure on use of mechanical lifts which required at least two persons to be present while a resident was transferred with the mechanical lift. 4. To train licensed nurses and a certified nursing assistants (CNAs) on use of Sabina II EE mechanical lift and selection of lifting accessories to ensure safe transfer.These deficient practices resulted in Resident 1 sustaining a fracture of the left humerous (upper arm) and left forearm with a soft tissue swelling, experiencing unbearable pain and to be admitted to a general acute care hospital (GACH) for two days.These deficient practices presented an imminent danger of death or of serious harm to the resident, or a substantial probability of death or serious physical harm to the resident. |
| 910000036 |
THE EARLWOOD |
910013242 |
A |
8-Jun-17 |
W7WI11 |
11680 |
F 323
?483.25 (h) Accidents
The facility must ensure that ?
(1) The resident environment remains as free from accident hazards as is possible: and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
The facility failed to ensure the residents? environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to:
1. Failure to follow Resident 1?s assessment and plan of care in providing the necessary care and supervision to prevent accidents.
2. Failure in using a two-person physical assist and a Hoyer lift (mechanical resident lift) to transfer Resident 1.
3. Failure in reporting Resident 1?s injury immediately.
These deficient practices of not following Resident 1's care assessment resulted in the residents' left leg being caught in the wheelchair after an alleged fall on November 29, 2016, sustaining a left ankle fracture (broken bone), with a delay in diagnosing and treatment, and requiring a transfer to a general acute care hospital (GACH). After being diagnosed with a left ankle fracture, Resident 1 required a deep vein thrombosis (DVT [blood clot]) prophylaxis of Lovenox (anticoagulant therapy [to help reduce the risk of developing a DVT]) 30 milligram injection every 12 hours for 10 days and pain medication (Mobic 15 mg once a day).
On December 13, 2016, an announced complaint investigation was conducted after the Department received a complaint regarding Resident 1 complaining of pain, after sustaining a fall with a swollen left ankle.
At 12:45 p.m., on December 13, 2016, during a concurrent observation and interview, Resident 1 was observed lying in bed with a cast (holds a broken bone in place as it heals) on her left leg. Resident 1 was unable to move her bilateral (both) lower extremities. Resident 1 was interviewed regarding the incident and the resident stated that her physician had told her the left ankle was broken. Resident 1 was interviewed regarding what happened and the resident stated she had just finished receiving a shower when a Certified Nursing Assistant (CNA1) had to get someone to assist her back onto the wheelchair from the shower chair. Resident 1 stated that was when the "trouble started," because they turned her, but not fast enough and her foot was caught in the wheelchair. Resident 1 gestured toward her wheelchair, pointing at the wheelchair's footrest.
A review of Resident 1's Admission Face Sheet indicated the resident was an 86 year-old female who was admitted to the facility on XXXXXXX 2015. Resident 1's diagnoses included hemiparesis and right hemiplegia (paralysis of the right side of the body [dominant side]), hypertension (high blood pressure) and dementia (brain disease with gradual decrease in ability to think and remember).
A review of Resident 1's history and physical (H/P) examination, dated October 21, 2016, indicated the resident had a history of left-sided hemiplegia status post a cerebrovascular accident (stroke), with right lower extremity weakness and was non-ambulatory.
A review of Resident 1's Minimum Data Set (MDS), an assessment and care screening tool, dated November 30, 2016, indicated Resident 1's cognition (mental process of knowing) was intact. The resident had a BIMS (brief interview for mental status) score 13 (8-15 indicated interviewable) with good memory recall. According to the MDS, Resident 1 was non-ambulatory (unable to walk) and was totally dependent on staff for transferring and required a two-person physical assist. The MDS, under Section GO300, for balance transitions, indicated Resident 1 was not steady with surface to surface transfer and required assistance from the staff to stabilize. Under Section G0400; Functional Limitation in Range of Motion, indicated Resident 1 had impairment of the lower extremities on both sides.
A review of a Resident 1's care plan, initiated on November 7, 2015, and last revised on November 6, 2016, titled "At Risk for Falls," indicated Resident 1 had an actual fall on October 6, 2016. The plan of care indicated the resident was at risk for further falls due to impaired mobility, poor gait and balance, poor safety awareness and advanced age. The staff's interventions did not include the resident's assessment of requiring a two-person physical assist with transferring with the use of a Hoyer lift.
A review of Resident 1's care plan, revised on May 3, 2016, indicated the resident required extensive assistance and was dependent for activities of daily living (ADLs), including bathing, transferring and locomotion.
At 1 p.m., on December 13, 2016, during an interview, the facility's physical therapist (PT) stated Resident 1 was dependent with mobility and transfers and was non-weight bearing (cannot bear weight) on the left side. A review of the PT's note, dated December 5, 2016, indicated Resident 1 was referred to the PT due to new onset of a fracture. According to the PT's note, the resident was sent to the ER per the family's request and was diagnosed to have a left ankle fracture with a left leg cast.
On December 20, 2016 at 1:30 p.m., during an interview, CNA 1, who transferred Resident 1 on the day of the incident (XXXXXXX 2016), stated she gave Resident 1 a shower in a shower chair without using a Hoyer lift to transfer. CNA1 stated after Resident 1's shower she took the resident back to the room, but needed assistance to transfer the resident from the shower chair to the wheelchair. CNA 1 stated there was no other CNA available, so she attempted to transfer Resident 1 by herself and when she realized she was unable, she went and asked a Licensed Vocational Nurse (LVN 1) to assist her. CNA 1 denied that Resident 1 hit the footrest of the wheelchair, but she was not sure if the resident's foot hit any part of the wheelchair. CNA 1 stated, "I was unaware that the resident (Resident 1) required a two-person assist and a Hoyer lift for transferring. I had not received an endorsement from the previous shift or the charge nurse regarding the need for a two-person assist."
A review of the facility's investigation report, dated December 2, 2016, indicated CNA1 did not receive help from LVN 1 in transferring Resident 1 from the shower chair to the wheelchair. The report indicated CNA 1 transferred Resident 1 by herself.
A review of a Resident 1's PT's Assessment Summary, after the fall with a fracture, dated December 5, 2016, indicated Resident 1 was dependent on staff for all functional mobility since admission (October 21, 2015). The PT Summary indicated Resident 1 required the use of a Hoyer lift for transferring due to CVA affecting extremities, poor trunk and postural control, and bilateral ankle contractures (the result of stiffness or constriction in the connective tissues of your body).
On December 13, 2016 at 2:10 p.m., during an interview, CNA 2, who frequently cared for Resident 1, stated the resident was "total care" and received a shower twice a week. CNA 2 stated the resident required a two-person physical assist in transferring with a Hoyer lift from the bed to the shower chair.
At 3:50 p.m., on December 13, 2016, CNA 3 stated that during the 3 to 11 p.m. shift, on November 29, 2016, Resident 1 complained her left foot was hurting. CNA 3 stated Resident 1 told her that after a morning shower, while CNA 1 was moving her foot, it hit the floor.
A review of Resident 1's ADL Record for the month of November 2016, indicated the CNAs documented the resident was "D2" which indicated Resident 1 was totally dependent upon staff in transferring and required two or more staff members to assist with the transfer.
A review of electronic nurses' note, dated November 29, 2016 and timed at 11:14 p.m., indicated Resident 1's family member (FM) inquired about the possibility of the resident falling that day after a shower. According to the note, the FM informed the nurse of Resident 1's complaint of falling after her morning shower. The nurses' note indicated the CNAs for the morning shift were both gone. The note further indicated the charge nurse went and asked the evening CNA and she told the charge nurse that the morning CNA "was a little rough with the resident's legs" and Resident 1 was complaining of leg pain.
A review of Resident 1's paramedic EMS [emergency medical services] Report, dated December 1, 2016 without a time of arrival, indicated the resident was found in bed alert complaining of left ankle pain. The EMS Report indicated the resident's ankle was injured during a shower.
A review of Resident 1's GACH emergency department (ED) record indicated the resident arrived on December 1, 2016 at 2:19 p.m. The ED's history indicated the resident had complained of left ankle pain for two days, after being dropped two days prior. A review of Resident 1's left ankle x-ray results taken in the ER, dated December 1, 2016 and timed at 3:49 p.m., indicated Resident 1 sustained a transverse fracture (a rare injury, usually results from a sudden extreme twisting or side bending movement) of the distal tibia and fibular bone (further end of the lower leg) diaphysis (portion of the long bone where it meets the extremities). Resident 1 was diagnosed with a closed fracture of the distal end of the left fibula (ankle). According to the ER records, Resident 1's left leg required a splint (a rigid material used for supporting and immobilizing a broken bone when it has been set), and later a cast. The GACH's discharge instruction indicated the facility's (SNF) nursing staff should be cautious with moving the resident.
On May 15, 2017 at 3:52 p.m., during a telephone interview, Resident 1's FM stated he was the one who questioned the facility on December 1, 2016, after visiting and saw Resident 1's left ankle was red, swollen and she complained of pain. The FM stated he attempted to talk to the facility's social worker about what happened, but she would not give him any answers. The FM was upset and called adult protected services (APS), who informed him to call 911(emergency services), which he did. The FM stated the paramedics arrived and stated the left foot was swollen and looked fractured. The paramedics put a splint on the left ankle and transported Resident 1 to the GACH. The FM stated Resident 1 had told him before that the facility usually banged her feet on things during transfer on the Hoyer lift. The FM stated he was told by a facility's nurse (unnamed) that the CNA had dropped Resident 1.
A review of the facility's policy, revised on May 12, 2016, titled "Safe Resident Handling Program," indicated transfer assistance, mobility and other resident handling tasks, are to be carried out in accordance with the lift/ transfer assessment and care plan.
The facility failed to ensure the residents? environment remained as free from accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents, including but not limited to:
1. Failure to follow Resident 1?s assessment and plan of care in providing the necessary care and supervision to prevent accidents.
2. Failure in using a two-person physical assist and a Hoyer lift (mechanical resident lift) to transfer Resident 1.
3. Failure in reporting Resident 1?s injury immediately.
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 910000036 |
THE EARLWOOD |
910013254 |
A |
8-Jun-17 |
W7WI11 |
11238 |
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.
The facility failed to provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, including but not limited to:
1. Failure to ensure pain medication (Norco [Hydrocodone 10 milligrams (mg) with 325 mg of Acetaminophen] a narcotic pain medication used for moderate to severe pain]) that was prescribed by the physician was available.
2. Failure to ensure medication not prescribed was not administered without a physician's order to Resident 2.
3. Failure to follow its policy in ordering medications.
These deficient practices resulted in Resident 2 having unrelieved severe body pain for over 36 hours due to not receiving the prescribed as needed (PRN) dose of Norco, which resulted in the resident's inability to sleep, have good mobility and quality of life. The facility also gave a medication (Tylenol 325 mg [pain reliever for mild pain]) without a physician's order, which had the potential for an adverse reaction.
a. On December 13, 2016 at 1:02 p.m., during an investigation of an unrelated complaint, a physician (Physician 1) was observed talking to Resident 2 about her pain. During a concurrent interview with Physician 1 she stated Resident 2 was currently in pain and was told by the nursing staff the resident could not get her pain medications "This morning."
At 1:20 p.m., on December 13, 2016, during a concurrent observation and interview, Resident 2 was observed lying in bed with a family member at the bedside. Resident 2 stated she had arthritis (a condition that caused pain and inflammation in the joints, the tissues that surround the joint, and connective tissue) and sciatica (of pain affecting the sciatic nerve, a large nerve extending from the lower back down the back of each leg). Resident 2 stated, "The pain is hot on my chest with pressure pain due to the arthritis." Resident 2 pointed to her left lower extremity and her left upper body, while making facial expressions, while being tearful, closing her eyes with facial grimacing and shaking her head. Resident 2 stated she was not given her pain medication and could not sleep the previous night due to the intense pain. Resident 2 described her pain level as being 10 out of 10 ([10/10] on the numeric scale, 10 being the worst). Resident 2 stated when she would lay back on the bed she had difficulty breathing and with back pain after not receiving her pain medication. Resident 2 stated the last time she received pain medication was "Yesterday morning" and stated she had told the nurses about her pain.
A review of Resident 2's Admission Face Sheet indicated the resident was a 78 year-old female who was admitted to the facility on XXXXXXX 2016. Resident 2's diagnoses included Polymyalgia Rheumatica (an inflammation syndrome characterized by severe pain and stiffness to the arms and legs), muscle weakness, and hypertension (high blood pressure).
A review of Resident 2's care plan titled, "Risk for Alterations in Comfort related to Acute Pain," dated December 5, 2016, with the goal for the resident to achieve an acceptable level of pain control within 14 days. The staff's interventions included to evaluate Resident 2's pain characteristics. There was documentation of Resident 2's pain being assessed after the facility ran out of the resident's Norco.
A review of Resident 2's Norco controlled drug record, titled "Controlled or Antibiotic Drug Record," the physician's order indicated for one tablet to be given by mouth every six hours as needed (PRN) for pain. According to the controlled drug record and bubble pack, the last dose of Norco 10/325 mg was given from the bubble pack to Resident 2 on December 12, 2016 at 1:30 a.m.
On December 13, 2016 at 1:30 p.m., during an interview, a registered nurse (RN 1) stated she was aware Resident 2 did not get her Norco pain medication, because the facility ran out of Resident 2's Norco and the physician had not signed the triplicate (the physician keeps one copy of the prescription for five years and sends two copies with the patient to the pharmacist [created to decrease drug diversion]) copy needed to order Resident 2's Norco. RN 1 stated she assessed the resident and she complained of a lot pain all over her body. RN 1 acknowledged she was aware that only the Norco medication relieved Resident 2's pain.
A review of Resident 2's nursing note, in the presence of RN 2, dated December 12, 2016, and timed at 4:43 p.m., indicated there was no documentation or pain assessment of Resident 2's pain, and as well as no documentation the resident's physician (Physician 1) was notified that Resident 2 was out of Norco, as was verified by RN 2.
On December 13, 2016, at 1:40 p.m., during an interview, Physician 1 stated she was not informed that Resident 2 had run out of Norco and that she was on call daily until 7 p.m. Physician 1 also stated she visited the facility every day, Monday through Friday, and no one had mentioned it.
At 1:45 p.m., on December 13, 2016, during a subsequent interview, RN 2 stated medications are re-ordered when there are five doses left in the bubble pack and that the charge nurses were responsible for reordering the medications.
b. On December 13, 2016, at 1:02 p.m., during a medication review of Resident 2's medications indicated the Norco 10/325 mg bubble pack (a type of packaging for medication) was empty. The narcotic control sheet indicated the last dose was given to Resident 2 on December 12, 2016 at 1:30 a.m.
On December 13, 2016, at 1:15 p.m., during an interview, a Licensed Vocational Nurse (LVN 2) stated she administered one tablet of Tylenol (acetaminophen) 325 milligram (mg) at 9 a.m. on December 13, 2016, since Resident 2 had ran out of Norco. A review of Resident 2's physician's orders and the Medication Administration Record (MAR), for the month of December 2016, indicated there was no physician's order to administer Tylenol. LVN 2 stated she gave Resident 2 the Tylenol medication to relieve her pain because "We don't have anything (Norco) right now." LVN 2 was asked if there was physician's order for Resident 2 to receive Tylenol 325 mg LVN 2 stated, "No."
A review of Resident 2's physician's orders, dated December 5, 2016, indicated there was no order for Tylenol.
During an interview, on December 13, 2016, at 1:30 p.m., RN 1 was informed that LVN 2 administered Tylenol to Resident 2 without a physician's order. RN 1 stated, "It is a medication error, if the medication was given without a doctor's order." RN 1 stated she had assessed Resident 2 earlier after she had complained of pain all over her body and acknowledged she was aware the only medication that worked to relieved Resident 2's pain was Norco.
On May 17, 2017, at 10:52 a.m., during a telephone interview, the Director of Nurses (DON) stated the facility have an emergency kit (E-Kit [an extra supply of drugs to be given by mouth or intravenous [into the vein] during an emergency or when the residents' medications were not available). The DON was asked if Norco was in the E-Kit and she stated, "Yes." The DON faxed a list of the medication in the E-Kit, titled "Controlled (C2 thru C5 [control drug level]) Drug Emergency Kit," and it indicated there were 16 tablets of Norco 10/325 mg in the E-Kit. The DON stated if a resident ran out of medications, including Norco then the nurses should get the medication from the e-kit and administer to the resident. The DON stated a triplicate was not required for the Norco to be given. The DON stated she was not sure why Resident 2 did not receive the medication (Norco) and should have, especially since it was in the E-kit.
At 1:10 p.m., on May 17, 2017, the DON called back after reviewing Resident 2's narcotic controlled record and stated the last time the resident received the Norco was on December 12, 2016 at 1:30 a.m., and the physician (Physician 1) ordered more Norco on December 13, 2016. Resident 2 received the Norco the same day (December 13, 2016) at 8:30 p.m. (after the facility was informed of Resident 2's findings on December 13, 2016), over 36 hours after the last dose of Norco was given to the resident. The DON stated all the nurses were aware that Norco was in the E-Kit, but she did not understand why the nurses did not give it. The DON was asked if a nurse can give medications (Tylenol) without a physician's order and she replied, "No." The DON stated, "That is Nursing 101, all medications require a physician's order." The DON also stated the nurses are all aware that all narcotics should be reordered when there were five doses left in the bubble pack.
On May 18, 2017 at 11:20 a.m., during a telephone interview, the facility's dispensing pharmacy pharmacist in charge (Pharmacist 1) stated a triplicate was not needed to dispense Norco. Pharmacist 1 stated the physician was required to write a prescription only. He stated the pharmacy received a "STAT" faxed order for a refill of Norco for Resident 2 on December 13, 2016, timed at 2:24 p.m. Pharmacist 1 stated the Norco for Resident 2 left the pharmacy on December 13, 2016 at 7:30 p.m. and arrived at the facility at 10 p.m. Pharmacist 1 was asked if Norco was taken from the facility's E-kit and he stated, "Norco 10/325 mg was taken out of the E-kit on December 13, 2016 at 1:46 p.m., and again on the same day at 8:20 p.m.
A review of the facility's policy, revised on January 2, 2014, titled "Medication Errors," indicated a medication error was defined as a discrepancy between what the physician ordered and what the patient received.
A review of the facility's pain management policy, with a revision date of November 28, 2016, indicated the purpose of the policy was to maintain the highest possible level of comfort for residents by providing a system to identify, assess, treat and evaluate pain. The policy also stipulated that the nurse would notify the physician, as appropriate, and obtain orders as indicated.
The facility failed to provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, including but not limited to:
1. Failure to ensure pain medication (Norco [Hydrocodone 10 milligrams (mg) with 325 mg of Acetaminophen] a narcotic pain medication used for moderate to severe pain]) that was prescribed by the physician was available.
2. Failure to ensure medication not prescribed was not administered without a physician's order to Resident 2.
3. Failure to follow its policy in ordering medications.
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 910000336 |
The Rehabilitation Center of Santa Monica |
910013283 |
A |
19-Jun-17 |
5E0Y11 |
14398 |
F323
(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.
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
F309
483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
The Department received an Entity Reported Incident (ERI), dated 2/8/17 alleging a resident (Resident 1) urinated on the side of his bed, slipped and fell. Resident 1 sustained a fractured (a break in the bone) left femur (thigh bone).
On 2/9/17 at 10:30 a.m., an unannounced complaint investigation was conducted.
Based on observation, interview and record review, the facility failed to provide Resident 1 with the necessary care and services to attain or maintain the highest practicable physical, mental and psychological well-being in accordance with the comprehensive assessment and plan of care, and failed to ensure that Resident 1 who was assessed as a high risk for falls and had a history of a seizure disorder receive adequate supervision and assistance devices to prevent accidents by not:
1) Following the physicians order to Monitor Wander-Guard (a device that alarms when residents attempt to elope or wander from a safe environment) placement for Resident 1.
2) Conducting 15 minutes checks to ensure placement of the bed alarm and Wander Guard
3) Revising the plan of care and notify the physician when Resident 1, turned off his Wander Guard, bed alarm and attempted to get out of the bed and wheelchair without calling for assistance.
These deficient practices resulted in Resident 1 falling and complaining of pain to his left hip. Resident 1was transferred to the acute hospital for an evaluation of his left hip pain, where he was diagnosed with a left femur (thigh) fracture (a break in the bone). Resident 1 stayed in the acute hospital for eight days, and underwent a left hip hemiarthroplasty (a surgical procedure that replaces one half of the hip joint with an artificial limb).
A review of the admission record indicated Resident 1 was admitted to the facility on XXXXXXX 16, with diagnoses that included schizophrenia (a mental disorder characterized by failing to understand what is real) and major depressive disorder (mental illness characterized by persistent feelings of sadness and hopelessness).
A review of the admission assessment dated 10/13/16, indicated Resident 1 required assistance with ambulation and transfers.
A review of Resident 1's fall risk assessments dated 10/13/16, indicated a score of 16, and on 1/24/17 a score of 18. According to the fall risk assessment a total score of 10 or above represents a high risk for falls.
A review of the Risk Meeting (a team that identifies and prevents problems from occurring) Team Notes dated 10/14/16, indicated Resident 1 was at risk for falls, and was offered a body alarm monitor for safety purposes, but the staff noticed the resident had more aggressive behaviors as a result. The Risk Meeting Team Notes further indicated the interventions were not appropriate and can only pose as a risk. and the Interdisciplinary Team (IDT) would review the approaches, monitor and modify if indicated. Resident 1 was maintained on fall precautions at all times.
A review of the physician's orders dated 10/17/16, indicated to monitor Wander-Guard placement and function every shift. Apply Wander- Guard to alert staff when resident attempts to leave the facility and to monitor the whereabouts of the resident every shift due to risk for wandering and elopement.
A review of the Minimum Data Sheet (MDS-a standardized assessment and screening tool) dated 10/24/16, indicated Resident 1 was cognitively impaired and was dependent on staff for toileting, transfers, eating and personal hygiene. The assessment also indicated Resident 1 was always incontinent (lack of voluntary control over urination or defecation) of bladder function, used a walker and a wheelchair as mobility devices. The Care Area Assessment (CAA) of the MDS indicated Resident 1 triggered the area of falls, urinary incontinence and noted a fall risk care plan would be developed.
A review of Resident 1's plan of care titled "Falls" dated 10/26/16, indicated the resident was at risk for falls due to a history of falls, balance problems, wandering and anti-anxiety, anti-depressant, or hypnotic medications. The listed interventions included to provide assistance in transfers and mobility, conduct a fall risk assessment quarterly or as needed, address identified risk factors, identify the time of the day the resident is most vulnerable to falls and provide a safety reminder.
A review of an undated plan of care for Resident 1 titled "Non-Compliant" indicated Resident 1 was non-compliant with morning care. The care plan further indicated Resident 1 was unable to be re-directed, became aggressive and belligerent with the staff and was observed urinating on the floor. The listed interventions included to monitor Resident 1's whereabouts and to keep the Wander-Guard in place.
A review of the Nursing Weekly Summary dated 1/12/17, indicated Resident 1 ambulated alone, required limited assistance with one person, used the grab bars for positioning, did not sustain a fall and had a low bed. The Weekly Summary did not contain information regarding use of a Wander Guard.
A review of the Nursing Weekly Summary dated on 1/19/17, indicated Resident 1 propelled himself with a wheelchair for long distances, and required limited assistance with one person physical assistance, used a grab bar for positioning, did not sustain a fall and had a low bed. The Weekly Summary did not contain information regarding use of a Wander Guard.
A review of the Situation, Background, Assessment and Recommendation (SBAR- a licensed staff communication tool) dated 2/5/17, at 5 a.m., indicated on 2/5/17 at 4:30 a.m., Resident 1 was calling out for assistance and was found lying in a supine (on the back) position on the floor in his room. According to the SBAR Resident 1 fell on the floor as a result of urinating on the floor and complained of pain to the left hip and thigh area and was assisted back to bed. The SBAR did not contain information regarding use of a Wander Guard.
A review of the physician's orders for Resident 1 dated 2/5/17, at 5:30 a.m., indicated to obtain an x-ray (a painless test that produces images of the structures inside of the body) of both hips and the left lateral (on the side) femur. The x-ray report for Resident 1 dated 2/5/17, indicated Resident 1 sustained a left neck femur fracture.
A review of the facility's investigative report dated 2/5/17 indicated Resident 1 was assessed and noted to be a high risk for falls upon admission on 10/13/16. The investigative report did not contain documentation as to the cause of the fall and did not include information regarding the use of a Wander Guard.
A review of the "Resident Transfer Form" dated 2/6/17, indicated Resident 1 was transported from the facility to the GACH via gurney by a private ambulance company at 11:50 a.m., the following day due to a fractured left femur.
During interviews on 2/9/17, at 1:20 p.m. and 2 p.m., with the Assistant Director of Nursing (ADON), she stated Resident 1 was able to ambulate, but had an unsteady gait and usually used a wheelchair for mobility.
During an interview on 2/10/17, at 12:38 p.m., the Registered Nurse Supervisor (RNS) stated Resident 1 fell on 2/5/17 at 4:30 a.m.
A review of the acute hospital history and physical (H &P) dated 2/12/17, Resident 1 had an unwitnessed ground level fall at the nursing home and was found to have a femur neck fracture. Resident 1 underwent a left hip hemiarthroplasty.
During a telephone interview on 5/8/17 at 9:48 a.m., Licensed Vocational Nurse (LVN 1) indicated on 2/5/17, Resident 1 had gotten out of the bed and displayed non-complaint behaviors, which included, turning off his bed alarm and attempting to get out of bed and/or wheelchair without calling for assistance. LVN 1 stated when the resident disarmed his bed alarm, staff made visual rounds every 15 minutes. LVN 1 was asked to provide documentation of the "every 15 minute" rounds. LVN 1 stated the documentation is located on the Medication Administration Record (MAR) form. LVN 1 further stated Resident 1 had a bed alarm due to multiple falls in the past. The resident also had a Wander guard bracelet because he attempted to elope from the facility. Resident 1 was not able to ambulate independently, used a walker and a wheelchair and would hold on to the door or the hallway rail and had balance issues. LVN 1 stated Resident 1 required assistance to the bathroom, and was provided a urinal and a diaper, but he would continuously urinate on the floor. She further stated Resident 1 would not use the call light to call for assistance, however he was placed next door to the nurses station, but he would somehow manage to maneuver himself partially out of the bed where the bed alarm would not sound off. She also stated Resident 1 did not have one to one monitoring.
During a review of Resident 1's clinical record there was no documented evidence the plan of care was revised to address Resident 1's identified behavior of disarming and turning off his bed alarm and attempting to get out of the bed and wheelchair without calling for assistance. This was confirmed via interview with LVN 1 on 5/8/17, at 9:48 a.m.
During an interview on 5/8/17 at 10:20 a.m. the Certified Nurses' Assistant (CNA 1) stated Resident 1 would get very aggressive if he could not get his way. CNA 1 stated although the resident had a urinal he would not use the urinal, yet urinated on the floor. CNA 1 further stated prior to the resident's fall on 2/5/17, he was not able to walk independently, had a chair and an ankle alarm. CNA 1 was not able to recall if Resident 1 had a bed alarm prior to 2/5/17.
During an interview on 5/8/17, at 11:10 a.m., the Director of Nursing (DON) stated Resident 1 was close to the nurses' station with frequent nursing rounds by the RN's, LVN's, and Certified Nurses' Assistants (CNA's). The DON was asked when the current measures were not effective for Resident 1, what other plans of care did the facility have in place for the resident. The DON stated the facility would contact the resident's conservator, use personal safety alarms such as an alarm for the bed and the wheelchair. The DON was asked if Resident 1 had a plan of care in place for disarming the bed alarm. The DON stated "no." The DON was asked how the staff monitored the resident's safety needs, she stated the staff performed bed alarm checks and the staff documented the checks on the MAR.
During a telephone interview on 5/8/17, at 11:55 a.m., CNA 2 stated on 2/5/17, Resident 1's bed alarm was on but he would turn off the alarm. Resident 1 required assistance with ambulation. The resident was assisted to the bathroom and back to bed. Resident 1 would urinate in the bed and on the floor. CNA 1 was asked if he performed bed alarm checks every 15 minutes, CNA 2 stated "no."
During a review of Resident 1's MAR's for the months of 11/2016, 12/2016, 01/2017 and 02/2017, there was no documentation of bed alarm checks by the staff. Furthermore, there was no documentation of bed alarm checks in the residents' entire clinical record from admission to the facility on XXXXXXX16, to the time the resident was transferred to the GACH on XXXXXXX17.
A review of the facility's revised policy dated on 5/2011 and titled "Fall Prevention" indicated a fall prevention program will be developed for each patient that will provide patient care staff with creative functional strategies to minimize falls and undue injuries from such incidents, while recognizing the patient's rights and their need to maintain the highest level of functioning.
A review of the facility's revised policy dated on 8/9/13, titled "Fall Prevention (Falling Star)" indicated the following criteria will be utilized by the facility's IDT to determine the appropriateness of Patient/Resident to be included in the program.
The "Fall Prevention" policy further indicated residents who are placed on the Falling Star Program will be assessed by the IDT for appropriateness of interventions for safety. Interventions may include, but not limited to, depending on Patient/Resident-specific safety needs as follows:
-Use of pressure pad/alarm (safety alarms).
-Initiating "safety watch" -Safety watch is done every 30 minutes, on the hour by the Licensed Nurses, and 30 minutes by the CNA's. Schedule is documented in the Licensed Nurses/ CNA's assignment sheets.
The IDT will evaluate for need of the Patient/Resident to be placed on:
a. Close Supervision- Patient/Resident is placed within the areas with direct view of facility staff, such as closer to the nurses' station, activities, dining room, etc.
b. One-on-One Monitoring- If close supervision fails and resident may be at increased risk for hurting self/others, an employee will solely be assigned with the resident at a designated time of the day, which could be twenty four (24) hours a day/ seven (7) days a week, depending on Patient/Resident specific needs and assessment/judgement by the IDT.
The facility failed to:
1) Follow the physicians order to Monitor Wander-Guard (a device that alarms when residents attempt to elope or wander from a safe environment) placement for Resident 1.
2) Conduct 15 minutes checks to ensure placement of the bed alarm and Wander Guard
3) Revise the plan of care and notify the physician when Resident 1, turned off his Wander Guard, bed alarm and attempted to get out of the bed and wheelchair without calling for assistance.
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. |
| 910000336 |
The Rehabilitation Center of Santa Monica |
910013284 |
A |
19-Jun-17 |
VMQK11 |
12803 |
F323
(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.
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.
F309
483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
The Department received an Entity Reported Incident (ERI), dated 2/8/17 alleging a resident (Resident 1) urinated on the side of his bed, slipped and fell. Resident 1 sustained a fractured (a break in the bone) left femur (thigh bone).
On 2/9/17 at 12:30 p.m., an unannounced complaint investigation was conducted.
Based on interview and record review the facility failed to follow the physician's orders by not:
1. Providing floor mats to prevent accidents and injuries.
2. Maintaining a safe environment for Resident 1 who was assessed as a high risk for falls and had a history of falls.
This deficient practice resulted in Resident 1 sustaining a left hip and left clavicle (the collarbone) fracture (a break in the bone) that required surgery to repair the left hip. Resident 1 was transferred to a general acute care facility (GACH) where she underwent an Open Reduction Internal Fixation (ORIF-surgical repair of broken bones by re-aligning the bone back to a normal position with steels rods or screws) for an intertrochanteric (between the inner bony part of the thigh bone that are attached to the thigh muscles) left hip fracture.
A review of the admission record indicated Resident 1 was admitted to the facility on XXXXXXX17, with diagnoses that included dementia (a condition characterized by a group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning), muscle weakness, difficulty walking and a history of falling.
A review of the inter-facility transfer order report from the general acute care hospital (GACH) dated XXXXXXX17, indicated on 1/25/17, Resident 1 fell at home and sustained fractures in two areas of her neck. The Physical Therapist (PT) assessment dated 1/28/17, indicated Resident 1 had poor awareness of safety precautions, a fall risk, impaired balance and a decreased knowledge of precautions. The PT's recommendations indicated that the resident should wear a cervical collar at all times.
A review of the undated admission assessment indicated Resident 1 was incontinent (lack of voluntary control over urination or defecation) of bowel and bladder, spoke and understood Farsi (an Iranian language) and wore a #1 collar brace around her neck.
A review of Resident 1's fall risk assessment dated 1/31/17, indicated a score of 22. According to the fall risk assessment a total score of 10 or above represented a high risk.
A review of the physician's orders for Resident 1 dated 1/31/17, indicated to use a low bed and place the bed to the lowest position to reduce and minimize injuries from a fall. The orders further indicated to monitor proper placement of the low bed every shift.
A review of the physician's orders dated 1/31/17, also included orders to use floor mats and to place floor mats while in bed to reduce/minimize injury from a fall. The orders included to monitor placement of the floor mats every shift.
A review of Resident 1's plan of care titled "Falls" dated 1/31/17, indicated the resident was as risk for falls/injury due to a history of falls, a fractured neck and balance problems. The listed interventions included to use a low bed, floor mats, and to place the bed in a low position to reduce/minimize injuries from fall and to monitor proper placement of the floor mats and the low bed every shift. The interventions further indicated to place floor mats while in bed to reduce/minimize injury from a fall. Monitor placement every shift.
A review of the Medication Administration Record (MAR) dated from 2/1/17 to 2/6/17 indicated Resident 1 was being monitored for having floor mats at the bedside on the following shift 7 a.m. to 3 p.m., 3 p.m. to 11 p.m., and 11 p.m. to 7 a.m.
A review of the Minimum Data Sheet (MDS-a standardized assessment and screening tool) dated 2/6/17, indicated Resident 1 was cognitively impaired, dependent on the staff for toileting, transfers, eating and personal hygiene and had functional limitations in range of motion to his upper and lower extremities. The MDS further indicated the resident had a fall prior to admission that resulted in major injury that included bone fractures, joint dislocations, closed head injuries with altered consciousness (any measure of arousal other than normal) or subdural hematoma (bleeding around or within the brain).
A review of the Situation, Background, Assessment and Recommendation (SBAR- a licensed staff communication tool) dated 2/6/17 timed at 9 p.m., indicated while walking down the hallway a visitor in the facility observed Resident 1 lying on the floor next to her bed. The resident was assessed and complained of left shoulder and hip pain. The physician was notified and ordered to transfer the resident to the GACH's emergency room department for a fracture evaluation.
A review of the physician's orders for Resident 1 dated 2/6/17, at 10 p.m. indicated to transfer the resident to the GACH's emergency room for a fracture evaluation on the lower and upper extremities (hands and feet). Resident 1 was transferred to the GACH on XXXXXXX17 at 10:50 p.m.
A review of the physician's History and Physical from the GACH dated 2/7/17 indicated Resident 1 stated that she was in severe pain, movement of her neck was painful and the left hip was swollen and deformed (misshapen). Resident 1 sustained a fracture to the left hip and the left clavicle in which a left hip open reduction and internal surgical fixation (ORIF- surgical repair of broken bones by re-aligning the bone back to a normal position with steels rods or screws) was performed on the same day.
A review of the facility's investigative report dated 2/8/17 indicated Resident 1's fall was an unavoidable incident despite the facility's efforts, interventions including adequate supervision, consistent with the resident's needs, goals and plan of care in order to reduce the risk.
During an interview on 2/10/17 at 8:45 a.m., Resident 2 stated that on 2/6/17, she observed Resident 1 lying on the floor. Resident 2 further stated when Resident 1 was lying on the floor; she did not recall hearing a bed alarm and Resident 1 did not have any floor mats on the side of the bed.
During a telephone interview on 2/10/17 at 11:25 a.m., Licensed Vocational Nurse (LVN 1) stated during the evening on 2/6/17 he observed Resident 1 lying on the floor. Resident 1 was lying on her back with half of her body parallel to the bed and the other half of her body was under the bed. LVN 1 stated that the resident's left leg was under the bed and the right leg was observed on the outer part of the bed. LVN 1 further stated that Resident 1 was at risk for falls, was on bedrest due to a previous neck injury and did not have a floor mats next to the bed.
During an interview on 2/10/17 at 1:05 p.m., the Assistant Director of Nursing (ADON) stated Resident 1 was a high risk for falls and had a care plan in place for falls that included a low bed and floor mats.
During an interview on 5/8/17 at 1:59 p.m., Certified Nurses' Assistant (CNA 1) stated Resident 1 was resistant to general care and at times made an attempt to climb out of the bed. Resident 1 would tightly grab a hold of the bed rails and her clothing. CNA 1 stated on the day in question she believed Resident 1 had a bed alarm and if the bed alarm is not positioned accurately in the middle of the bed, the alarm would not sound off.
During an interview on 5/8/17 at 1:50 p.m., CNA 2 stated Resident 1 was not able to walk and believed that she had a bed alarm. On the day in question after provided evening care for the resident, the rails were up and the bed was lowered to the floor. CNA 2 stated that she did not observe any floor mats.
During a telephone interview on 5/9/17 at 11:26 a.m., LVN 1 stated that he could not recall if Resident 1 had a bed alarm. The resident was in a room farther away from the nurses station and was unable to visualize the resident from the nurses" station.
During a telephone interview on 5/9/17 at 11:51 a.m., the Family Member (FM 1) stated that she made daily visits with Resident 1 and she would stay in the facility most of the day. Prior to the admission at the facility Resident 1 was able to walk with a walker, but now she is unable to walk. FM 1 stated on 2/6/17, the resident did not have any floor mats near or surrounding the bed and was unsure if the resident had a bed alarm. FM 1 further stated during a meeting with the facility's staff, the facility's staff indicated that residents' may fall because they were unable to provide one-to-one nursing for the residents' who were a high risk for falls and required supervision.
During a telephone interview on 5/15/17 at 10:58 a.m., the Administrator stated the facility does not have a policy indicating the licensed nurses are to follow the physician's orders.
During a telephone interview on 5/15/17 at 1:56 p.m., FM 2 stated on 2/6/17, between 6pm to 7 pm , she was walking down the hallway to the residents' dining area when she observed Resident 1's feet poking out from the floor; the resident was lying on the floor in a supine (on the back) position in between her bed and bed B. FM 2 further stated she reported this to the Supervisor.
A review of the facility's revised policy dated on 5/2011 and titled "Fall Prevention" indicated a fall prevention program will be developed for each patient that will provide patient care staff with creative functional strategies to minimize falls and undue injuries from such incidents, while recognizing the patient's rights and their need to maintain the highest level of functioning.
A review of the facility's revised policy dated on 8/9/13 and titled "Fall Prevention (Falling Star)" indicated the following criteria will be utilized by the facility's IDT to determine the appropriateness of Patient/Resident to be included in the program included the following:
a. Patient/Resident is using a personal safety alarm for fall prevention/intervention.
The "Fall Prevention" policy further indicated residents who are placed on the Falling Star Program will be assessed by the IDT for appropriateness of interventions for safety. Interventions may include, but not limited to, depending on Patient/Resident-specific safety needs:
-Use of pressure pad/alarm (safety alarms)
-Use of low bed and/or ensuring that the bed is at its lowest position.
-Use of matt in the floor-one on both sides.
-Out of bed /back to bed schedule.
-Initiating "safety watch" -Licensed Nurses and CNA's working during the shift are given schedules on making rounds with the main focus of safety practices observation, which may include: Patient/Resident with indication for low bed have their beds at the lowest position, most especially after care is provided, ensuring floor is dry and clutter-free, among other possible safety precautions necessary. Safety watch is done every 30 minutes, on the hour by the Licensed Nurses, and on the 30 minutes by the CNA's. Schedule is documented in the Licensed Nurses/ CNA's assignment sheets.
The IDT will evaluate for need of the Patient/Resident to be placed on:
a. Close Supervision- Patient/Resident is placed within the areas with direct view of facility staff, such as closer to the nurses' station, activities, dining room, etc.
b. One-on-One Monitoring- If close supervision fails and resident may be at increased risk for hurting self/others, an employee will solely be assigned with the resident at a designated time of the day, which could be twenty four (24) hours a day/ seven (7) days a week, depending on Patient/Resident specific needs and assessment/judgement by the IDT.
The facility failed to follow the physician?s orders by not:
1. Providing floor mats to prevent accidents and injuries.
2. Maintaining a safe environment for Resident 1 who was assessed as a high risk for falls and had a history of falls.
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. |
| 920000003 |
The Grove Post-Acute Care Center |
920009103 |
B |
15-Mar-12 |
MZXP11 |
9221 |
Code of Federal Regulations Section 483.25(h) 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 staff failed to evaluate and analyze the risk hazards for Resident 8?s behavior of holding a cigarette too close to his right middle finger causing the resident to sustain a right middle finger, closed blister with discoloration, which resulted from a cigarette burn. Furthermore, the facility staff failed to adequately supervise the resident, consistent with the resident's needs in accordance with the current standard of practice.On October 11, 2011, from approximately 6 p.m. until 6:30 p.m., during the Recertification survey, Resident 8 was observed sitting in his wheelchair smoking a cigarette outside in the patio area, designated as the facility's smoking area. Resident 8 was observed constantly moving in his wheelchair by leaning forward and crossing and uncrossing his legs. Resident 8 was holding the lit part of his cigarette very close to his right middle finger.The Certified Nursing Assistant (CNA 1) who was in charge of supervising the smoking area, assisted Resident 8 five times by repositioning his cigarette so the lit part would be away from his right middle finger. CNA 1 finally told Resident 8, "You've smoked this one enough," and took the cigarette away, replacing it with a newly lit cigarette. CNA 1 was assisting the smoking residents by handing out cigarettes, lighting cigarettes, telling some residents to flick their ashes and asking other residents not to share their cigarettes. CNA 1 was supervising a total of 15 residents who were scattered throughout the patio smoking area.During this observation, Resident 8 had a discolored closed blister on his right middle finger, directly underneath the lit part of his cigarette. When Resident 8, was asked what happened to his finger, he said, "I burned it with the cigarette."The Admission Record revealed Resident 8, a 64 year old male, was admitted to the facility on October 10, 2008, with diagnoses which included muscle weakness and being a chronic smoker.The Annual Minimum Data Set (MDS) assessment for Resident 8 dated August 10, 2011, indicated the resident was assessed as having minimal difficulty hearing, unclear speech, usually understood, inattention and disorganized thinking with some behaviors present and fluctuating.A review of the physician's order dated February 23, 2010, revealed an order for Artane 2 milligram (mg), one tablet by mouth every day for extrapyramidal symptoms [( EPS) an inability to initiate movement and/or an inability to remain motionless]. Resident 8?s Resident Smoking Assessment dated October 10, 2008, which had not been updated, revealed his diagnoses included schizophrenia. The comprehension assessment indicated the resident was confused and disoriented at times, but was able to answer simple questions. The behavior was assessed as easily getting anxious, and the physical assessment revealed the resident had weakness.However, there was no assessment regarding Resident 8's constant EPS movements and his habit of holding the lit part of his cigarette too close to his right middle finger. The interdisciplinary team (IDT) recommendations were to supervise smoking, smoking materials to be secured at nurse's station, and that the plan had been reviewed with the resident/responsible party. Resident 8's smoking assessment failed to reveal specifically what type of supervision the resident required given his behavior of holding a lit cigarette too close to his right middle finger and his constant movements.A review of Resident 8's care plan dated October 10, 2008, reviewed August 10, 2011, revealed the resident smoked frequently especially after meals, was able to hold his cigarette, had no limitation on dexterity, preferred to smoke rather than taking his meal, and was diagnosed as a chronic smoker. There was no mention about the resident?s behavior of holding his lit cigarette until it burned down far enough to burn his right middle finger, or his constant movements.The care plan goal was that he would be able to exercise his right to smoke within the limits of safety, which was to be reviewed in 90 days. One of the approaches was to offer a safe environment for the resident. However, there were no approaches/interventions to safeguard Resident 8?s right middle finger while smoking.A review of the physician's order dated October 11, 2011, revealed to cleanse the resident?s right middle finger closed blister with discoloration, with normal saline, pat dry, then apply triple antibiotic ointment and cover with a dry dressing twice a day for 30 days. The orders directed staff to monitor the resident?s right middle finger closed blister for any further changes of color, shape, and appearance for 30 days.A review of the non-pressure skin condition report dated October 11, 2011, revealed the resident was assessed as having a closed blister with discoloration of the right middle finger, 0.8 centimeter (cm) by 0.8 cm. The probable cause was from the resident's smoking. On October 12, 2011, at approximately 3:15 p.m., using the facility's interpreter, CNA 1 was asked specifically how Resident 8 smokes. He stated Resident 1 holds his cigarette very close to his finger. CNA 1 then proceeded to demonstrate using a pen in between his right middle finger and the index finger, with the tip of the pen (indicating the lit part of the cigarette) kept very close to the right middle finger. CNA 1 was asked if he noticed Resident 8's discolored and reddened right middle finger. He stated he did about a month ago, but there was no redness, only yellowish discoloration.CNA 1 was asked how many times he had to reposition Resident 8's lit cigarette when he noticed the resident holding the lit part too close to his right middle finger. He stated he had to reposition the resident?s cigarette about four or five times, because the resident kept smoking it all the way to the end of the filter, and the lit part of the cigarette was too close to his finger. CNA 1 was asked if Resident 8 had a habit of smoking his cigarettes down too far, close to his right middle finger, to which he replied, ?Yes.? CNA 1 was asked if he notified anyone about Resident 8's habit of smoking his cigarette too close to his right middle finger. He said people already knew.CNA 1 was asked if he was able to supervise all 15 residents in the smoking area yesterday on October 11, 2011, by himself, he stated, ?No.? CNA 1 was asked if he was ever educated and or informed how to monitor the smoking residents, specifically regarding their needs and habits, and he stated, ?No.? On October 12, 2011, at approximately 8:50 a.m., the Central Supply person was asked if she also supervised residents when they were smoking. She stated she did perform this task on Monday thru Friday at 8 a.m., 10 a.m., and 2 p.m. She also said she usually supervised approximately 12 residents during the 2 p.m. smoking scheduled time, and that she tries to supervise all of them, but it was difficult to watch everyone when she was by herself. On October 12, 2011, at approximately 10:15 a.m., the Director of Staff Developer (DSD) stated an in-service titled ?Improving Observation and Reporting Skills during Smoking Time,? was given to all CNAs, which was dated May 2, 2011. The subject was the residents will have scheduled smoking breaks without any injuries, protective aprons will be provided to residents that require them, CNAs will stay with the residents until they are done smoking, CNAs will monitor residents while smoking and will report injuries/incidents to charge nurse/department heads, and CNAs will bring all residents who are confused inside the facility. However, there was no mention regarding how many residents one CNA was able to safely supervise. A review of the facility's policy and procedure, titled ?Resident Smoking Assessment? revealed the objective was to provide a safe environment by assessing residents who smoke if he/she is physically and mentally capable of keeping cigarettes, carrying a lighter, and following the smoking policy. A review of the facility?s final investigation letter to the Department dated October 14, 2011, revealed the facility concluded the cause of Resident 8's right middle finger closed blister with discoloration was the result of a smoking incident.The facility staff failed to evaluate and analyze the risk hazards for Resident 8?s behavior of holding a cigarette too close to his right middle finger causing the resident to sustain a right middle finger, closed blister with discoloration, which resulted from a cigarette burn. Furthermore, the facility staff failed to adequately supervise the resident, consistent with the resident's needs in accordance with the current standard of practice.The above violations had a direct relationship to the health, safety, and security of Resident 8, and all other residents in the facility who require supervision while smoking. |
| 920000067 |
TARZANA HEALTH AND REHABILITATION CENTER |
920009538 |
B |
03-Oct-12 |
FPSO11 |
11282 |
42 CFR 483.12 (b)(1) &(2) Notice of Bed Hold F 205 Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the nursing facility, and the nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (b)(3) of this section, permitting a resident to return.At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section.Resident 1 who was admitted to the hospital on August 22, 2012, was ready to return to the skilled nursing facility on August 24, 2012. The resident required skilled nursing services and was eligible for Medicare and Medi-Cal.The facility failed to: 1.Provide Resident 1 with a written seven-day bed hold notice before the resident was transferred to the acute care hospital on August 22, 2012. 2.Re-admit Resident 1 during the seven-day bed hold period on August 24, 2012, resulting in violation of the resident's right for re-admission to the facility for one out of one sample resident.On August 30, 2012 at 12:30 p.m., an investigation was initiated to investigate an allegation that Resident 1 was denied readmission to the facility. According to a review of the resident's admission record, the resident was admitted to the facility on February 16, 2012, with diagnoses that included debility (weak feeble), bipolar disorder, osteomyelitis (bone infection) and anorexia. The Minimum Data Set (MDS) assessment, dated September 11, 2012, indicated the resident had moderately impaired cognitive skills for daily decision making, required limited assistance with one person physical assistance in transfers, not ambulating and required total assistance in activities of daily living. The MDS indicated the resident did not have any behavioral symptoms but had trouble falling or staying asleep, had little energy, was feeling bad about herself and had trouble concentrating on things such as reading the newspaper or watching television. On August 24, 2012, the Social Worker from the acute care hospital informed the Department of Public Health Licensing and Certification that the skilled nursing facility refused to readmit the resident.During interviews with the Director of Nursing (DON) on August 30, 2012, at 1 p.m., and with the Administrator on September 10, 2012, at 2:10 p.m., both stated the resident was not given a seven day bed-hold notice at the time of the resident's transfer to the acute hospital.In addition, the clinical record failed to reveal any documented evidence that the facility provided the resident a seven day bed-hold notice on August 22, 2012. On September 10, 2012, at 8:45 a.m., during an interview on August 22, 2012, the acute care hospital Social Worker said, the resident was received in the hospital emergency room with the facility's physician's order for the "resident not to return to the facility under any circumstances." Also, she stated that on August 24, 2012, the facility was called and informed that the resident was ready for discharge back to the facility, and then the DON informed her that the facility did not intend to readmit the resident back following her stay at the acute care hospital. On August 30, 2012, at 1 p.m., a review of the resident's record indicated there was a physician's order, dated August 22, 2012, signed by the facility's Medical Director to transfer the resident via 911 to the emergency room and not to return the resident to the facility under any circumstances. During an interview with the DON on August 30, 2012, at 1 p.m., she stated the resident was transferred to the acute care hospital after exhibiting extreme agitation and physically aggressive behavior toward staff and another resident. The DON said that there were no triggers for the resident's aggressive behavior and that it was entirely unprovoked. The DON also stated that the facility employed various interventions to address the challenges the resident posed and added that they did not wish to increase the dosage or frequency of the resident's psychotropic medications. The DON explained that on August 22, 2012, the night the resident was transferred out to the hospital, the facility contacted the resident's primary care physician to determine the course of action.According to the Change of Condition form, dated August 22, 2012, at 4 p.m., the resident was noted continuously yelling, screaming and swinging her legs and hands.According to an interview on September 10, 2012, at 3:45 p.m., with a Registered Nurse (RN 1) and a record review, on August 22, 2012, at 4 p.m., while seated in a wheelchair, Resident 1 was noted to be agitated and had an aggressive behavior episode which led the resident to hit two staff members and one resident on that day. Based on the above RN 1 interview and a review of the licensed nurse?s notes, the resident's primary care physician was contacted on August 22, 2012, at 4 p.m. The physician told the licensed nurses, "you know that she has a psych problem just give all her medication and she will be OK."A review of the Medication Administration Record (MAR) for August 2012, indicated the resident was administered Ativan 0.5 milligram (mg) as needed (PRN), for anxiety manifested by agitation from August 6 to 19, 2012, but the medication was not administered on August 20, 21 or 22, 2012. The start date for the Ativan order was April 25, 2012. In addition, the MAR indicated the resident was not administered Seroquel 50 mg for agitation on as need basis for psychosis manifested by agitation as ordered on August 20, 21 or 22, 2012. The start date for the Seroquel order was May 24, 2012.According to the interview with the DON and a record review, the facility then contacted their Medical Director who responded with an order to transfer the resident to the acute care hospital. The order also stated that the resident was a risk to others and should not be returned under any circumstances.On September 5, 2012, at 11:30 a.m., State of California Department of Health Care Services conducted a Refusal to Readmit Appeal hearing at the acute care hospital, where the resident currently resides. According to the record of the hearing, the facility did not conduct a clinical assessment of the resident's current status while the resident was at the acute care hospital. It was documented that the facility asserted to the hearing officer that the resident would be better served at another type of facility where her psychiatric needs could be more adequately met.The record indicated the resident's primary care physician was attending the hearing and stated that he had been a care provider for the resident for many years, including being her attending physician at the facility and he was also following her at the acute care hospital. The physician stated that the resident was mainly bed-bound and suffered from various ailments that render her physically unable to pose a risk to others.It was documented that the physician stated that when he visited the resident at the hospital after her admission there, she was at her baseline status of functioning and behavior, and remained at that level.The record also indicated the primary care physician opposed the facility's assertion that the resident was not appropriate for readmission back to the facility. The physician stated that the resident's challenging behavior was brought on her by psychiatric diagnosis, however with her prescribed psychotropic medications and other treatment received from the psychiatrist at the facility, the resident was doing well. It was documented that the resident's physician expressed frustration that the intention of the facility's medical director was to "dump" the resident at the hospital. According to the hearing report the resident's psychiatrist, who also attended the hearing, concurred that the facility was the best place for the resident to reside and that she could be cared at the facility safely. It was documented that the psychiatrist suggested that the facility utilize more intensive interventions to identify triggers that provoke undesirable behavior and use staff that the resident likes as an approach to minimize her outbursts and aggressive behavior. According to the review of the resident's clinical record on September 10, 2012, at 3:30 p.m., there was no documented evidence that the facility had attempted to identify possible triggers which could provoke the resident's aggressive behavior.During an interview with the facility's Administrator on September 10, 2012, at 2:10 p.m., he questioned the psychiatrist recommendation on utilizing the staff the resident liked to minimize her outburst of anger by saying.." and how he expect me to do that?'' According to the psychiatric evaluation, dated September 6, 2012, conducted by the acute care hospital psychiatrist, "...at times the resident becomes somewhat more labile depend[ing] on the care provider..." The hearing report indicated that the acute care hospital staff, who also attended the hearing, agreed that the resident did not present with acute care need and was approved for discharge on August 23, 2012. According to the hearing record the resident was conscious of the hearing purpose and expressed her desire to return to the facility. The resident did not attend the hearing but authorized the Ombudsman to represent her.According to the hearing report, the hearing officer concluded that resident was currently not in need of acute psychiatric or medical treatment and her discharge back to the facility was appropriate and supported by federal regulations. The final decision/order from the Office of Administrative Hearing and Appeals was for the facility to readmit the resident back to the facility. The decision order read, "... Rehabilitation Center must immediately readmit the resident..." On September 10, 2012, at 2:10 p.m., the Administrator said, "as of today my decision is not to readmit the resident." As of October 1, 2012 the facility had not readmitted Resident 1 from the acute care hospital. The facility failure to:1.Provide Resident 1 with a written seven-day bed hold notice before the resident was transferred to the acute care hospital on August 22, 2012. 2.Readmit Resident 1 during the seven-day bed hold period on August 24, 2012, resulting in violation of the resident's right for readmission to the facility. This violation caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to Resident 1 who was currently not in need of acute psychiatric or medical treatment and her readmission back to the facility was appropriate and supported by federal regulations. 1 |
| 920000312 |
TOTALLY KIDS SPECIALTY HEALTHCARE-SUN VALLEY |
920009791 |
A |
18-Jul-13 |
UVBN11 |
11063 |
42 CFR ? 483.25 Quality of Care - F 328 The facility must ensure that residents receive proper treatment and care for the following special services: Respiratory Care On November 29, 2012 at 1:05 p.m., an unannounced visit was made to investigate a complaint that a three year old child, who pulled out her Tracheostomy tube, had a cardiac arrest and died. Based on interview and record review, the licensed nurses and respiratory therapists failed to ensure that Resident 1 received proper respiratory care and treatment by failing to: 1. Have a system in place to prevent self decannulation (the expulsion of the Tracheostomy tube from the trachea). 2. Closely monitor this resident who had a history of pulling out her Tracheostomy tube. She was able to pull the tube out while the certified nursing assistant (CNA) was in the room and died as a result of removing the tube that helped her to breathe. Findings: According to the admission information, Resident 1 was three years old, originally admitted to the facility on July 17, 2009, with diagnoses that included: Chronic Pulmonary Heart Disease (according to The Free Dictionary, chronic pulmonary heart disease is the enlargement and eventual failure of the right ventricle of the heart due to disorders of the lungs or their blood vessels or chest wall abnormalities), 24 completed weeks of gestation, chronic respiratory failure (according to The Free Dictionary, chronic respiratory failure is a life-threatening condition in which respiratory function is inadequate to maintain the body?s need for oxygen supply and carbon dioxide removal while at rest), pulmonary hemorrhage (according to the University of California San Francisco, a pulmonary hemorrhage is a discharge of bloody fluid from the upper respiratory tract), seizure disorder (according to The Free Dictionary, a seizure is a sudden disruption of the brain?s normal electrical activity accompanied by altered consciousness and/or other neurological and behavior manifestations) and Tracheostomy(according to the American Journal of Nursing, March 2002, Vol. 102, No. 3 a Tracheostomy is the creation of an opening into the trachea through the neck, with insertion of an indwelling tube to facilitate passage of air or evacuation of secretions).Resident 1 had the following physician orders: 1. May 19, 2012, Resident 1 was to wear bilateral hand mittens as needed to prevent self decannulation (the expulsion or removal of the Tracheostomy tube from the trachea). Take the mittens off every two hours and check for circulation.2. August 13, 2012, have on a continuous pulse oximeter. According to Wikipedia a pulse oximeter is a medical device that indirectly monitors the oxygen saturation of a patient?s blood. The blood oxygen monitor displays the percentage of arterial hemoglobin.3. October 31, 2012, to receive 21% (oxygen concentration in the ambient air) cool aerosol. According to the care plan dated June 11, 2012, Resident 1 was at risk for self-decannulation related to upper extremity mobility. The interventions included applying mittens or arm immobilizers while awake daily. The care plan also indicated all disciplines were to document the use of the mittens/arm immobilizers on the treatment record. The care plan, dated August 19, 2012, indicated the problem/concern was Tracheostomy tube dislodgement (decannulation). The plan included to secure the Tracheostomy tube with the correct size ties and ensure proper tightness. Resident 1 was transferred to the acute care hospital via paramedics on October 19, 2012, after she pulled out her Tracheostomy tube. According to the History and Physical report completed by the acute care hospital physician dated October 19, 2012, Resident 1 pulled out her Tracheostomy tube and was found cyanotic (blue) and pulseless by her care giver at the facility. Cardio-pulmonary resuscitation (CPR) was necessitated. She recovered with spontaneous respirations and strong pulses after one minute. It is unknown how long she was decannulated prior to being found by facility staff. Following stabilization, Resident 1 was transferred to another acute care hospital on the same day where she had a second episode of pulling out her Tracheostomy tube. CPR was administered again until Resident 1 had spontaneous respirations. She was discharged from the acute care hospital and readmitted to the facility on October 31, 2012.According to the STAT (Statim ? at once) Team Record form, dated November 9, 2012 at 7:40 p.m., Resident 1?s Tracheostomy tube was pulled out again and she was unresponsive. The staff called 911 as the respiratory therapist was reinserting the Tracheostomy tube. CPR was initiated. The paramedics arrived and took Resident 1 to an acute care hospital for evaluation and treatment. The Physician Consultation report dated November 10, 2012, recommended, ?more gentle reinsertion of Tracheostomy tube should the patient self-decannulate again? and preventive measures and increased monitoring to prevent self-decannulation. The Nurse?s Notes dated November 22, 2012 at 1:08 a.m., written by registered nurse (RN) 1 indicated a STAT was called to Resident 1?s room. When she arrived four respiratory therapists (RT?s) were in the room securing the new Tracheostomy tube and started chest compressions. There were also three licensed vocational nurses (LVN) in the room. Around 1:15 a.m., the paramedics were called. They arrived at 1:20 p.m. and took over. The ordering physician (the paramedics were in contact with via the phone) stopped the CPR. The resident was pronounced dead at 1:32 a.m. at the facility. The Pre-hospital Care Report Summary completed by the Los Angeles Fire Department Paramedics dated November 22, 2012, indicated Resident 1 had a history of pulling out her Tracheostomy tube. According to the report the nurse at the facility told the paramedic she checked on her around 1 a.m., and she was moving around. The nurse left the room to check on another resident and returned around 1:10 a.m., to find Resident 1 had removed her Tracheostomy tube and was not breathing and pulseless. They called 911 and initiated CPR. The paramedics arrived and took over. Resident 1 was pronounced dead at 1:38 a.m. The Death Certificate dated November 29, 2012, indicated Resident?s immediate cause of death was asphyxia (death resulting from lack of oxygen) caused by dislodgement of Tracheostomy tube, chronic lung disease and extreme prematurity. The Death Certificate also indicated the Tracheostomy tube became dislodged during the night. On December 4, 2012 at 2:50 p.m., during an interview, respiratory therapist (RT) 2 said on the night of the incident, he was coming back from lunch and heard the STAT call around 1:07 a.m. When he got to the room, RT 2 was already in the room with RT 1 trying to reinsert the Tracheostomy tube. CPR was initiated. The paramedics arrived and took over. RT 2 said Resident 1 was successful at pulling out her Tracheostomy tube several times. RT 2 went on to say the RT?s do not have a device to keep Resident 1 from pulling out her Tracheostomy tube. The nurses use mittens or a foam board (prevents the resident from bending her arm) and pulling out her Tracheostomy tube. During an interview with certified nursing assistant (CNA) 1 on December 4, 2012 at 3:30 p.m. she said on the night of the incident, she was in Resident 1?s room at the time Resident 1 pulled out her Tracheostomy tube, but she was providing care for another resident in bed D. LVN 1 came into the room and noticed Resident 1?s Tracheostomy tube was out. LVN 1 told CNA 1 to call a STAT. The appropriate disciplines responded and CPR was administered. CNA 1 further stated there was always someone in the rooms at all times, but she was busy with another resident in bed D and did not hear Resident 1 moving around. When asked if Resident 1 had any mittens on at the time of the incident, she said LVN 1 had taken them off. When asked why LVN 1 took the mittens off, she said the physician?s order indicated the mittens were to be released every two hours, and the resident was asleep when LVN 1 took them off. CNA 1 said she also takes the mittens off to clean the resident, but immediately puts them back on. On January 31, 2013 at 12:05 p.m., during an interview RN 1 said she was the charge nurse on duty the night of the incident. She heard the STAT call, ran to Resident 1?s room and the STAT Team was already there. The STAT Team secured Resident 1?s airway. According to RN 1 secured meant they reinserted the Tracheostomy tube. RN 1 said LVN 1 thought she reinserted the Tracheostomy tube but it was not in all of the way. Resident 1?s neck and face were so swollen (because of the medication she was taking) it was hard to see the Tracheostomy area. When the RT?s arrived, they were successful at reinserting the Tracheostomy tube. RN 1 also said there was supposed to be someone in the room at all times. RN 1 went on to say at the time of the incident, Resident 1 had on a cool aerosol mask over her Tracheostomy tube and had on a pulse-oximeter. According to RN 1, LVN 1 said the pulse oximeter did not display any numbers and the alarm was not sounding. RN 1 said while they were doing CPR the pulse oximeter was displaying numbers and working fine. When the paramedics arrived they took the pulse oximeter off of Resident 1. The paramedics arrived at 1:14 a.m. and stopped CPR at 1:20 a.m. RN 1 added Resident 1 had pulled her Tracheostomy tube out many times. On February 4, 2013 at 10:10 a.m. during an interview LVN 1 (who found the resident decannulated and unresponsive) stated CNA 1 was in the resident?s room at the time Resident 1 decannulated herself. According to LVN1 she had instructed CNA 1 to keep an eye on Resident 1 because the resident was at a high risk to pull out her Tracheostomy tube and she [the resident] had removed her Tracheostomy tube several times in the past. However, the plan of care was not updated to include an intervention to monitor the resident from the bedside. LVN 1 during the interview further stated that she had instructed CNA 1 to stay in Resident 1?s room and watch the resident so that she would stop the resident 1 from pulling her Tracheostomy tube then LVN 1 left Resident?s room and when LVN 1 returned to the resident?s room after ten minutes, LVN 1 discovered Resident 1?s Tracheostomy tube was pulled out and she did not see the hand mittens applied. LVN 1 stated she reinserted the Tracheostomy and told CNA 1 to call a STAT.The facility failed to: 1. Have a system in place to prevent self-decannulation of Resident 1?s Tracheostomy tube. 2. Closely monitor Resident 1 who had a history of pulling out her Tracheostomy tube and was able to pull the tube out undetected while the CNA was in the room and died as a result. The above violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 920000312 |
TOTALLY KIDS SPECIALTY HEALTHCARE-SUN VALLEY |
920009807 |
A |
14-May-13 |
NF5Q11 |
13503 |
42 CFR - 483.85 Quality of Care - F328 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. Based on observation, interview, and record review, the facility failed to ensure that Resident 1, a four year-old pediatric resident who had a history of repeated self-decannulation (unplanned dislodgement) of the tracheostomy tube [a curved tube that is inserted into a tracheostomy stoma (a hole made in the neck and windpipe/trachea used as a temporary or permanent opening to allow airflow and permit the removal of secretions] would not self decannulate, that resulted in the resident?s death due to asphyxia (a condition of severely deficient supply of oxygen to the body) for one of one sample residents (1). by failing to: 1. Conduct a comprehensive assessment to identify the reason(s) Resident 1 repeatedly removed his tracheostomy and develop a plan of care with useful and effective interventions to prevent Resident 1 from removing the tracheostomy tube.2. Ensure that Resident 1 was continuously monitored and assessed for his breathing status and to ensure the tracheostomy tube was in place, kept clean and unobstructed with mucus and excessive secretions that would force Resident 1 to remove the tube due to air hunger (shortness of breath).3. Ensure that Resident 1's tracheostomy tube was securely and snugly tied around the neck to prevent the removal of the tube by the resident and/or during forceful coughing.4. Ensure that hand mittens were applied as ordered by the physician so that Resident 1 would not be able to remove the tracheostomy tube. On April 10, 2012, the Department received an entity reported incident that alleged a pediatric resident decannulated his tracheostomy tube on April 7, 2012 at approximately 1:00 p.m. and became unresponsive. The facility called 911 and the paramedics transferred the resident to an acute care hospital. Resident 1 did not recover from his medical emergency and died of asphyxiation (lack of oxygen) at the emergency room of the acute care hospital. An investigation of the above incident was conducted on April 20, 2012. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on January 3, 2012, with diagnoses that included chronic lung disease, ventilator dependent (a machine that does the breathing if the person's ability to breath independently is compromised) tracheostomy tube, gastrostomy tube (a surgical procedure for inserting a tube through the abdomen wall and into the stomach; the tube is used for feeding). A review of Resident 1's Minimum Data Set (MDS,) a standardized assessment, dated January 10, 2012, indicated Resident 1 had no speech, rarely/never understood, and rarely/never understand others and, was totally dependent on facility staff for ADL (activities of daily living). The MDS also indicated that Resident 1 was receiving oxygen therapy, suctioning, and tracheostomy care. There was a care plan, dated January 3, 2012, that identified a problem related to artificial airway, respiratory distress, chronic lung disease, prematurity and developmental delay. The care plan had goals that stated:1. There would not be episodes of respiratory distress. 2. Would not have stoma irritation. 3. Would not have tracheostomy tube dislodgement.The interventions of the care plan included:1. The Licensed nurses (LNS) and respiratory therapist/care provider (RCP) will assess Resident 1's respiratory status. 2. LNS and RCP will follow STAT [an emergency that compromises ABC airway, breathing, and circulation] Team procedure with any trach dislodgement. 3. Replace or clean trach tube with half-strength hydrogen peroxide every week as per MD order. 4. Spare trach tube with Resident 1 at all times. 5. If signs or symptoms of respiratory distress are observed, the LNS will do a complete assessment and notify the charge nurse and RCP. 6. Full vital signs every 6 hours and respiratory distress. 7. LNS/RCP will monitor for signs or symptoms of respiratory distress such as dyspnea (difficult or labored breathing; shortness of breath; dyspnea is a sign of serious disease of the airway, lungs), tachypnea (very rapid respiration), tachycardia (very rapid heartbeat), nasal flaring, chest retractions, and apnea (absence of breathing) for more than 20 seconds. 8.LNS/RCP will administer oxygen and medications as ordered. 9.Suction Resident 1 as needed for excessive secretions. 10. Stoma care per MD orders; sterile water every day. The above care plan was initiated by the multidisciplinary team that included the licensed nursing staff and the respiratory therapist, and was revised on April 3, 2012. However, a review of Resident 1's clinical record revealed Resident 1 had recurrent decannulation of the tracheostomy tube indicating the interventions mentioned in the care plan above were either not implemented properly and/or were not effective to achieve the stated goal on the care plan. For example: A review of Resident 1's clinical record indicated Resident 1 had removed his tracheostomy tube and that lead to deprivation of air/oxygen on the following dates: 1. A review of a facility STAT (immediate response) team record, dated March 16, 2012 at 7:00 p.m., indicated Resident 1 became agitated and decannulated his tracheostomy tube. Resident 1's oxygen saturation dropped to 63% (usual range is 92% ~ 100%), the tracheostomy tube was reinserted and Resident 1 recovered.2. A review of a facility STAT team record, dated March 17, 2012 at 9:20 a.m., indicated that a facility maintenance staff heard Resident 1's ventilator alarming. The report also indicated that the unit desk person checked Resident 1 and she noticed that Resident 1's tracheostomy tube was out. The report indicated that a RT unsuccessfully reinserted Resident 1's tracheostomy tube on the first attempt. The report also indicated that Resident 1's oxygen saturation dropped to 76% and Resident 1 turned cyanotic (bluish discoloration of the skin due to lack of oxygen in the blood). 3. A review of a facility STAT team record, dated March 25, 2012 at 7:52 p.m., indicated Resident 1 again decannulated his tracheostomy tube. Resident 1's oxygen saturation dropped to 52%. By 7:57 p.m., Resident 1 recovered and STAT was called off at 8:00 p.m. While Resident 1 decannulated himself on repeated occasions, there was no documented evidence that indicated the multidisciplinary team assessed Resident 1 to identify the cause(s) of Resident 1's behavior to decannulate himself and remedy the problem accordingly.A review of Resident 1's care plan for tracheostomy tube dislodgement, dated March 25, 2012, indicated a plan of action to secure the tracheostomy tube with correct size ties to ensure proper tightness. However, there was no documented evidence that indicated the tracheostomy tube was secured with correct size ties to ensure proper tightness. A review of the facility nurse's notes, dated March 26, 2012, (time was unreadable) indicated an entry that Resident 1 was able to decannulate his tracheostomy tube and was a threat to self decannulate. The entry indicated Resident 1's physician was notified and an order for the use of hand mittens was obtained. A review of Resident 1's physician's order, dated March 26, 2012, indicated Resident 1 had an order to apply hand mittens as needed for repeated self-decannulation.A review of Resident 1's care plan for "threat to self-decannulation", dated March 26, 2012, indicated a plan of action that included hand mittens to bilateral hands. However, a review of Resident 1's treatment record from March 26, 2012 through April 7, 2012, indicated that the physician's order to apply hand mittens as needed was never implemented. A review of a facility STAT team record, dated April 7, 2012 at 1:00 p.m., indicated Resident 1 had decannulated the tracheostomy tube and was found cyanotic (a bluish or purplish discoloration of the skin due to deficient oxygenation of the blood) and unresponsive. The record did not indicate how long Resident 1 was without a tracheostomy tube. However, the record also indicated that a respiratory therapist (RT) reinserted Resident 1's tracheostomy tube without difficulty and that Resident 1 was receiving 100% oxygen and CPR (cardiopulmonary resuscitation - chest compressions and artificial breathing) was started.The record indicated at 1:07 p.m., 911 was called. At 1:08 p.m., Resident 1 was still cyanotic, unresponsive and the RT replaced Resident 1's tracheostomy tube. The STAT record indicated that facility staff tried to start an IV line twice, however they were unsuccessful. At 1:10 p.m. Resident 1's physician was notified and an order to transfer Resident 1 to the general acute care hospital (GACH) was obtained.A review of the emergency room (ER) report, from the acute care hospital, indicated the Fire Department Paramedics received a call from the facility at 1:06 p.m. The Paramedics arrived at the scene at 1:11 p.m. The Paramedic report indicated Resident 1 was unresponsive and was in cardiac arrest with no breathing. The Paramedic report indicated CPR with AED (automated external defibrillator) was performed, but Resident 1 remained unresponsive. The Paramedic report indicated Resident 1 was transported to the acute care hospital at 1:22 p.m. The acute care hospital ER report indicated Resident 1 arrived at 1:27 p.m., in full arrest, with no respirations and no pulse. The acute care hospital ER performed advanced CPR but this was unsuccessful. CPR was discontinued and Resident 1 was pronounced dead at 1:52 p.m. On April 20, 2012 at 12:50 p.m., during an interview, a certified nursing assistant (CNA 1) stated that she was in Resident 1's room when she heard the apnea alarm beeping, however the ventilator alarm was not beeping. CNA 1 stated that she called the STAT team immediately. CNA 1 could not recall if Resident 1's tracheostomy tube was decannulated when she first saw Resident 1 not breathing and Resident 1's skin turning to a bluish color.On April 20, 2012 at 1:05 p.m., during an interview, RT 1 stated that after the STAT team discovered Resident 1 was decannulated, he [RT 1] reinserted the resident's tracheostomy tube and gave artificial breathing to Resident 1 through an oxygen bag, but Resident 1 was not taking in oxygen with the old tracheostomy tube in place. RT 1 stated that they had to use an emergency (spare) tracheostomy tube while CPR was being performed. RT 1 stated that he doesn't know why the ventilator alarm didn't sound off. On April 20, 2012 at 1:15 p.m., during an interview, the RT supervisor stated that the old tracheostomy tube was not plugged with mucous (to interfere with breathing). The RT supervisor also stated that the facility RTs set the sensitivity of the ventilator alarms settings.On April 20, 2012 at 2:10 p.m., during an interview, RT 1 stated that changes to the alarm settings may be due to the alarms sounding off too often. RT 1 also stated that he did not make any alarm setting adjustments to Resident 1's ventilator the day of the incident. On April 20, 2012 at 2:55 p.m., during an interview, the RT supervisor stated that facility RTs should document when they make changes to ventilator alarm settings. On April 20, 2012 at 3:05 p.m., during an interview, a vocational nurse (LVN 1) stated that she was assigned to take care of the resident that day. LVN 1 stated that Resident 1 was not wearing hand mittens that day. On November 29, 2012 at 3:15 p.m., the director of nursing (DON) stated that there should be a staff member in all residents' rooms at all times to provide continuous monitoring.According to the Certificate of Death dated January 4, 2013, Resident 1's immediate cause of death included asphyxia, dislodgement of tracheostomy tube, and chronic lung disease. The facility failed to ensure that a four year-old pediatric resident, who had a history of repeated self decannulation of the tracheostomy tube, would not self decannulate, This failure resulted in the resident?s death due to asphyxia (a condition of severely deficient supply of oxygen to the body) for one of one sample resident (1) by failing to:1. Conduct a comprehensive assessment to identify the reason(s) Resident 1 repeatedly removed his tracheostomy tube and develop a plan of care with useful and effective interventions to prevent Resident 1 from removing the tracheostomy tube.2. Ensure that Resident 1 was continuously monitored and assessed for his breathing status and to ensure the tracheostomy tube was in place, kept clean and unobstructed with mucus and excessive secretions that would force Resident 1 to remove the tube due to air hunger (shortness of breath).3. Ensure that Resident 1's tracheostomy tube was securely and snugly tied around the neck to prevent the removal of the tube by the resident and/or during forceful coughing.4. Ensure that hand mittens were applied as ordered by the physician so that Resident 1 would not be able to remove the tracheostomy tube. 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. |
| 920000067 |
TARZANA HEALTH AND REHABILITATION CENTER |
920011720 |
B |
16-Sep-15 |
7SZE11 |
11207 |
F257 CFR483.15(h)(6) CFR 483.15(h)(6) The facility must provide comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 - 81ø F; The facility failed to maintain comfortable and safe temperature levels in three residents' rooms (38, 40 and 42) and provide cooling measures to protect compromised residents against heat stroke (a life-threatening condition with symptoms of high body temperature, rapid pulse, difficulty breathing, and confusion), dehydration (when the body loses water that is not replaced), and possible death, for eight of eight sampled residents (1, 2, 3, 4, 5, 6, 7, and 8). In addition, the facility failed to maintain the air conditioning (A/C) unit equipment during disruption of services. Temperatures were measured in the three affected rooms to range from 84 degrees Fahrenheit (F) to 89F. The deficient practice had no actual harm with the potential for serious harm that resulted in Immediate Jeopardy (IJ) to residents' health and safety. An IJ was called at 6:49 p.m., on August 13, 2015, in the presence of the Administrator and Director of Nursing (DON). The IJ was lifted on August 14, 2015, at 6:45 p.m., with the DON and Division District Rehabilitation Manager present.Findings: On August 13, 2015, at 2:53 p.m., the Department received a complaint alleging the facility was hot, without air conditioning, and no air was coming through the vents in Rooms 38, 40, and 42.On August 13, 2015, at 4:35 p.m., the external temperature was over 100 degrees Fahrenheit (F) according to the weather broadcasts. During the facility tour, accompanied by Registered Nurse 1 (RN 1) and the maintenance supervisor (MS), and during interviews while on tour, the following was observed: 1. There were three residents in Room 38 (Residents 1, 2, and 3), who were able to communicate and express their needs. The room temperature was between 85 to 88 degrees Fahrenheit (F) when taken by the Maintenance Supervisor (MS) with the facility's temperature gun. The residents needed assistance/supervision in locomotion in and out of the room. There was no air coming out of the A/C vent and a family member, and two residents (1, 2) stated that the room was hot and uncomfortable.2. Room 40 had three residents inside the room (Residents 4, 5, and 6). Residents 4 and 5 were observed lying in bed sleeping. Resident 4 had an ongoing gastrostomy tube (GT) feeding (feeding via tube into the stomach) and was using an oxygen concentrator at the bedside which gave off heat and made the area hotter. Resident 5 had a low air loss (LAL) mattress, an ongoing GT feeding, and was on oxygen at two liters per minute via nasal cannula. Resident 5 was using an oxygen concentrator at the bedside, which was giving off heat and making the room hotter. Resident 6 was able to communicate but speak a foreign language, and was sitting in bed. The room temperature was measured by the MS to be between 84F to 89F. There was no air coming out of the A/C vent.3. There were two residents in Room 42 (Residents 7 and 8) who were alert, awake, and oriented and were able to express their needs and concerns. Resident 8 was observed lying in bed and stated that he felt weak. He had tremors in his right fingers and he was sweating excessively. He stated he had a headache with a pain scale of 5 out of 10, (0 being the lowest and 10 being the most severe pain). There were two friends visiting with Resident 8 at the time. Resident 8 had an oxygen concentrator at the bedside, which was giving off heat, and made the area hotter. His roommate, Resident 7, was observed with a lap top at his bedside and a telephone. The room temperature was measured by the MS to be between 84F to 87F. There was an electric fan in the room to be shared by both residents. There was no air coming out of the vents. Residents 7 and 8, together with visitors of Resident 8, were angry and frustrated at the facility.During the tour, at about 4:40 p.m., the MS stated he discovered the air conditioner (A/C) was not working at about 2 p.m., and called the technicians immediately. The technicians were fixing the air conditioner (A/C) at the time of the interview, and after approximately 10 minutes, they left. According to the MS, the A/C had been fixed. When asked for the facility's policy and procedure regarding the room temperatures, he was not able to provide a policy, and stated that they do not have a policy.During an interview with the Administrator on August 13, 2015, at 4:40 p.m., he stated that he offered Residents 7 and 8 relocation to another room but they did not want to change rooms. It would have been a temporary move.At 5:15 p.m., the temperature of the rooms were measured by the MS as follows: 1. Room 38 was 86 degrees Fahrenheit; 2. Room 40 was 88 degrees Fahrenheit; and 3. Room 42 was 86 degrees Fahrenheit. During an interview on August 13, 2015, at 5:20 p.m. with Resident 8's Durable Power of Attorney 1 (DPOA 1), she stated Resident 8 didn't want to relocate, uses a hydraulic lift to get out of bed and the resident was comfortable with the certified nursing assistants (CNAs) in that station/unit. According to her, there were only few nurses who were trained to use the hydraulic lift with the use of the sling safely and properly. Resident 8 was unable to push his call light, so his roommate, Resident 7 was the one calling for him. These are the reasons why Resident 8 did not want to relocate. The residents were comfortable with each other.During an interview with Resident 7 on August 13, 2015, at 5:25 p.m., he stated that it was also hot last year. According to him, last Sunday (August 9, 2015) he was very sick. He stated they were not giving him ice water. On August 11, 2015, last Tuesday of this week, he stated he complained again. He was complaining about the hot room for about three weeks. He really got hot August 9 and August 12, 2015. He stated the thermostat was set at 70F. He stated that he talked to the MS about the temperature being hot, and there was no air coming out of the vents. He said, "I cannot dress less than this." He was wearing a resident's gown. He stated it is cold in the winter and hot in the summer. This is especially being next to the back door and with the heat coming in through the door, it just heats it up more. He state their room is next to the main door entrance for the employees, ambulance, and smoking area, and is open constantly 24 hours a day, seven days a week. "I feel extremely hot and sick and have been sweating for weeks." He stated he did not appreciate how the Administrator had treated him. He stated the Administrator told him to "suffer" when he didn't want to relocate to another room, and he was told the electric company requested everyone to turn the A/C to 78F.Resident 7 stated, "We are given a fan for two people and the maintenance person had a portable air conditioner in his office. Why do employees have preference before residents?" He said Resident 8 had also complained to different staff members in the facility from licensed nurses to CNAs. He complained to the extent that when he pushed the call button, they do not come since they had stated previously that they cannot do anything with the A/C. Resident 7 stated he did not want to relocate to another room either. To change his Internet service, it would cost him his phone, tablet, and television.He said there was no consideration for residents, and he felt that they were putting the residents' needs second.Resident 7 stated the Administrator was unprofessional and that was unacceptable.On August 13, 2015, at 5:45 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), while in room 42, he stated that he just arrived at work, and stated the room was hot. According to him, the facility said that they had fixed the A/C. He stated last week the residents (7 and 8) complained that their room was hot. And, about two to three weeks ago, there was also an issue with Room 42's temperature being hot. During this interview, Resident 7 stated the MS told him the A/C was fixed, but it wasn't. On August 13, 2015, at 5:50 p.m., during an individual interview with Resident 8, he stated he did not feel well, felt nauseous, had trouble following on things, had trouble pushing buttons, and he had a headache. He did not want to change his room because Resident 7 helped him a lot. The heat made him feel worse, and stated his headache was a pain level of 5 out of 10. They did not offer me anything except a room change and a fan. He had verbally expressed his frustration to the staff. The staff members did not do anything. He stated that he had an air mattress because of the open sores at the back of his thigh.On August 13, 2015, at 6 p.m., during an interview CNA 1 stated Room 42 was a little hot.On August 13, 2015, at 6:15 p.m., during an interview with the Administrator, he stated the rooms were warm only this afternoon. He stated he didn't know about the rooms being hot before now.On August 13, 2015, at 7 p.m., during an interview with the DON, she stated she heard that rooms were hot August 12, 2015. It had been brought up by the unit manager for Station 2 during the morning stand-up meeting. She stated the MS was aware because he was present during this meeting.At about 7 p.m., the MS placed a portable A/C unit in Room 38 and Room 42. When asked where the A/C units came from, he stated one was from the laundry and one was from his room. He then went to purchase a third portable A/C unit for Room 40, which was placed in use at about 7:30 p.m. On August 13, 2015, at 8 p.m., the MS measured the room temperatures to be within acceptable limits as follows: Room 38 was 73F to 79F; Room 40 was 81F; and Room 42 was 75F. On August 13, 2015, at 8:03 p.m., during an interview with Resident 3, using an interpreter, she stated she felt hot in her room (38). She said she thought there was a heater in her room and they could not fix it.On August 13, 2015, at 8:45 p.m., during an interview with the Administrator, he stated according to the MS, it was not part of his job to maintain a temperature/air conditioner log. The Administrator stated the MS did not keep a room temperature log.The facility failed to maintain comfortable and safe temperature levels in three residents' rooms (38, 40 and 42) and provide cooling measures to protect compromised residents against heat stroke (a life-threatening condition with symptoms of high body temperature, rapid pulse, difficulty breathing, and confusion), dehydration (when the body loses water that is not replaced), and possible death, for eight of eight sampled residents (1, 2, 3, 4, 5, 6, 7, 8). In addition, the facility failed to maintain the air conditioning (A/C) unit equipment during disruption of services. Temperatures were measured in the three affected rooms to range from 84 degrees Fahrenheit (F) to 89F. This violation had a direct relationship to the health, safety, and security of eight sample residents (1, 2, 3, 4, 5, 6, 7, and 8). |
| 920000067 |
TARZANA HEALTH AND REHABILITATION CENTER |
920011814 |
A |
16-Nov-15 |
4IKB11 |
14959 |
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) The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 9/3/15, at 11 a.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 sustaining a fall at the facility which resulted in a left hip fracture.Based on interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and that Resident 1, who was assessed as risk for falls, received adequate supervision and assistance devices to prevent accidents, including:1. Failure to accurately assess the resident's safety risk factors and hazards. 2. Failure to develop an initial plan of care with interventions to address the resident's identified risk for falls. 3. Failure to place the resident on the Falling Star Program (helps to identify and promote safety for residents with impaired mobility), pending the first interdisciplinary team meeting (IDT), per facility policy. 4. Failure to develop and revise a care plan with interventions to address the resident's identified change in mental status, prior to her fall. As a result, Resident 1 suffered a fall on July 25, 2015, with a fractured hip, required surgery on July 28, 2015, developed complications while hospitalized and ultimately died on August 20, 2015 in the acute care hospital.A review of the closed clinical record indicated Resident 1 was admitted to the facility, on July 20, 2015, and was discharged on July 26, 2015, to a general acute care hospital (GACH). Resident 1's diagnoses included recent back surgery, abnormal gait (a manner of walking or running), lack of coordination, and generalized weakness. A care plan developed, on July 21, 2015, for Resident 1's potential safety and fall risk related to her potential for falls, decreased safety awareness, and falls related to her disease process, indicated the resident would be free of falls or fall-related injuries as the goal. The care plan interventions included to initiate safety checks as indicated. There were no individualized / resident-specific interventions documented.A review of the Nursing Daily Skilled Charting assessment form, dated July 21, 2015, indicated Resident 1 was alert and oriented to person only (own name), had short-term memory loss, and had difficulty making herself understood and understanding others. The charting assessment form indicated the resident was incontinent of bowel and bladder, wore pads/briefs, and was not on a facility bowel and bladder program. Resident 1 had full range of motion to both left and right sides.The Charting Assessment form indicated Resident 1 required extensive one-person, weight-bearing physical assistance with bed mobility (moving to/from lying position, turning side to side and positioning body while in bed), transfers (moving between surfaces including to/from bed, chair, wheelchair, and standing position), eating, and toilet use (including transfers on/off toilet, cleaning/hygiene after elimination, and adjusting clothing). The assessment indicated the resident had partial weight-bearing ability and had impaired balance and gait. A review of the Fall Risk Evaluation form, dated July 21, 2015, indicated a score of 9 and placed Resident 1 in the 'low risk' fall category. A total score of 10 or higher indicated the resident was 'at risk' for falls. The fall risk evaluation form indicated two areas, 'balance problem while standing,' and 'balance problem while walking,' were not checked off or counted in the total score. These additional parameters would have raised the score to 11, placing Resident 1 'at risk' for falls. A review of the Physical Therapy (PT) Evaluation and Plan of Treatment form, dated July 21, 2015, indicated Resident 1 previously lived at home with family, and was expected to be discharged home from the facility. The resident was referred to PT due to new onset of pain, decrease in strength, reduced balance, and decreased functional mobility. The evaluation and treatment form indicated Resident 1 had impairments to her right and left hips, knees, and ankles, and indicated the resident felt unsteady when standing and walking.A review of the Occupational Therapy (OT) Evaluation and Plan of Treatment, dated July 21, 2015, indicated Resident 1 was oriented to self only and her safety awareness was impaired. The OT's clinical impression was the resident had decreased bilateral upper extremity strength, decreased balance, decreased functional tolerance, and decreased safety awareness, which limited her ability to perform her activities of daily living (ADLs).A review of the progress notes indicated the following: On July 22, 2015, a 72 hour care conference was held with Resident 1's responsible party. There was no documentation of the Falling Star Program made at this time.On July 25, 2015, at 12:15 p.m., a change of condition summary indicated at 10:40 a.m., Resident 1's family member was present and expressed some concerns about the resident. The family member stated Resident 1 seemed more confused than usual. The resident's physician was notified at 11 a.m. and the family member stated she would visit the resident later. On July 25, 2015, at 12:57 p.m., Resident 1's urine specimen was obtained for urinalysis and culture and sensitivity (to determine presence of a urinary tract infection (UTI) and to determine the most effective antibiotic for treatment. According to WebMD (2015), UTIs are among health problems which can cause confusion or decreased alertness). On July 25, 2015, at 9:18 p.m., the change of condition follow up indicated Resident 1 was alert with confusion.On July 25, 2015, at 10:25 p.m., the certified nurse aide (CNA) called out at 9:30 p.m. that Resident 1 was on the floor. The resident was found in sitting position with both legs folded under her buttocks. Resident 1 was alert, verbally responsive, and pointing toward the bathroom. The resident was assisted to wheelchair then to bed, and pointed to her right shoulder when asked if she had any pain.On July 26, 2015, at 2:56 a.m., Resident 1 was monitored for any adverse changes as a result of her fall, was started on intravenous antibiotics for her UTI, and had an x-ray of the right shoulder. On July 26, 2015, at 6:29 a.m., the change of condition summary indicated Resident 1 was noted with bruising on the left middle of back and left groin area. The resident had severe pain to left hip when moved. Pain medication was given as needed.On July 26, 2015, at 9 a.m., the change of condition follow up indicated a report was received regarding the resident's fall and a new change of condition regarding left hip pain and multiple discolorations to body. There were physician's orders to transfer Resident 1 to the acute hospital emergency room, due to continued pain in left hip area, which were carried out. A review of the Minimum Data Set (MDS, an assessment and care planning tool), dated July 26, 2015, indicated Resident 1 usually understood others and was usually able to make herself understood (though she was Russian speaking), had moderately impaired cognitive skills for daily decision-making, required extensive two person assistance with bed mobility, and extensive one person assistance with all ADLs.The MDS indicated Resident 1's balance was not steady, she was only able to stabilize with staff assistance, when moving from seated to standing, walking, turning and facing the opposite direction while walking, moving on and off the toilet, and when making surface to surface transfers.A review of the Nursing Daily Skilled Charting, dated July 25, 2015, at 7:45 p.m., indicated Resident 1 was incontinent of bowel and bladder, was not on a facility bowel and bladder program, and did not wear pads/briefs. The charting indicated the resident had strong left and right hand grips and full range of motion on both sides, which contradicted the assessments of the PT and OT. The charting indicated skilled services provided included management and evaluation of plan of care and observation/assessment of resident's condition.A review of a change of condition progress note, dated July 25, 2015, at 10:28 p.m., indicated at 9:30 p.m., Resident 1 was noted sitting on the floor in her room, the call light was not on. The progress note indicated "Not Applicable," for inquiry of the resident having experienced mental status changes, such as increased confusion. This contraindicated the clinical record documentation Resident 1 had become "more confused than usual," at 10:40 a.m., on the morning before the resident fell. There was no care plan to address Resident 1's mental status/confusion, and there were no interventions to address the resident's increased confusion documented the day of the resident's fall.A review of the Interdisciplinary Post Fall Review, dated July 27, 2015, indicated Resident 1 was seen in sitting position next to her bed by a CNA. Resident 1 stated she wanted to go to the bathroom, but she did not call for help, and did not use her call light before transferring unassisted from her bed.The post fall review indicated Resident 1 had Alzheimer's disease/dementia, change in medications, UTI, cognitive deficits, and had been admitted in the last 30 days. The review failed to indicate Resident 1 had unsteady gait and a room change in the last 7 days. During an interview with the Director of Nurses (DON), on October 23, 2015, at 2 p.m., she read Resident 1's care plan titled, "Resident Has Potential Safety and Fall Risk related to: Potential For Falls, Decreased Safety Awareness, Falls Related to Disease Process," initiated and revised on July 21, 2015. The DON stated the sole care plan intervention indicated to initiate safety checks as indicated, was not individualized for Resident 1 and failed to indicate interventions to provide safety and prevent falls for the resident. The DON stated there was no mention made of the Falling Star Program in the care plan. During an interview with Certified Nurse Aide (CNA 1), on October 23, 2015, at 3 p.m., she stated Resident 1 never used her call light, but just called out when she needed help.The facility's policy and procedure titled, "Fall Management," revised August 2012, indicated the facility would take a proactive approach for new residents and would consider new admissions at risk for falls until the resident was reviewed by the IDT (interdisciplinary team). New admissions would be placed on the Falling Star Program until reviewed by the IDT. The policy indicated if determined by the IDT, the resident was at risk, the Falling Star would be continued and interventions in the plan of care would be updated. The facility was responsible for implementing individualized interventions for each resident's fall risks. A review of the facility's policy and procedure titled, "Resident Assessment," revised June 2012, indicated during the facility's next scheduled Daily Care Management Meeting, the IDT would review the resident's record, determine additional assessments or care plan items that should be included, and evaluate for immediate needs including risks and interventions.The facility's policy and procedure titled, "Care Planning and Care Conference," revised October 2010, indicated the care plan must serve as a guide for care delivery and documentation. Each resident shall have an Initial Plan of Care developed within 24 hours of admission to the facility which addressed identified risk areas and residents' initial individual needs. The policy indicated when developing the individualized care plan for the resident, the nurse must consider all new admissions "at risk" for falls, therefore a fall care plan would be completed as part of the Initial Plan of Care. In addition, it was vital the direct care staff receive communication of the resident's needs and plan of care. A review of the Physician's Discharge Summary from the acute hospital, signed on October 2, 2015, indicated the following hospital course for Resident 1: The resident underwent ORIF (open reduction internal fixation, a type of surgery to fix broken bones) of the left hip, on July 28, 2015. While recovering, the resident had persistent discharge from the operative wound. A Wound V.A.C. (vacuum assisted closure, uses a vacuum dressing to promote wound healing) was applied. The resident developed altered mental status and was not able to swallow. A nasogastric tube (carries food and medicine to the stomach through the nose) was placed. The following day the resident was found with high residuals (stomach contents) and the tube was misplaced.The resident aspirated (food, liquids, saliva, or vomit breathed into the airways), and went into respiratory distress. The resident was transferred to the intensive care unit where she had seizure activity and showed signs of cerebral edema (swelling in the brain caused by presence of excessive fluid). The resident was intubated and received multiple blood transfusions. Her condition was discussed and the resident was made DNR (do not resuscitate). Her condition got progressively worse. Palliative care services were provided. The resident ultimately expired on August 20, 2015. The facility failed to ensure that the resident environment remained as free of accident hazards as possible and that Resident 1, who was assessed as risk for falls, received adequate supervision and assistance devices to prevent accidents, including:1. Failure to accurately assess the resident's safety risk factors and hazards. 2. Failure to develop an initial plan of care with interventions to address the resident's identified risk for falls. 3. Failure to place the resident on the Falling Star Program (helps to identify and promote safety for residents with impaired mobility), pending the first interdisciplinary team meeting (IDT), per facility policy. 4. Failure to develop and revise a care plan with interventions to address the resident's identified change in mental status, prior to her fall. As a result, Resident 1 suffered a fall on July 25, 2015, with a fractured hip, required surgery on July 28, 2015, developed complications while hospitalized and ultimately died on August 20, 2015 in the acute care hospital.The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 1. |
| 920000091 |
TOPANGA TERRACE |
920012159 |
AA |
15-Jul-16 |
R08311 |
15217 |
F328 42 CFR ?483.25 (k) Quality of Care. Special Needs. The facility must ensure that residents receive proper treatment and care for the following special services: (4) Tracheostomy care; (5) Tracheal suctioning; and (6) Respiratory care. F309 42 CFR ?483.25 Quality of Care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure that Resident 1, who had a tracheostomy tube [surgical opening in the neck (windpipe) to place a tube to enable breathing], received proper respiratory and tracheostomy care and services to prevent repeated self-decannulation (pulling out of the tube), including but not limited to, failure to: 1. Ensure Resident 1, who had exhibited a behavioral pattern of pulling out his tracheostomy tube, was continuously monitored to prevent him from this behavior. 2. Ensure Resident 1?s tracheostomy tube was securely tied to prevent repeated self-decannulation. 3. Ensure Resident 1?s plan of care was updated to include interventions necessary to prevent self-decannulation of the tracheostomy tube in accordance with the facility?s protocols, including continuous one-to-one monitoring, and an equipment alarm to alert the staff without a delay if self-decannulation occurs. As a result, Resident 1 pulled out (decannulated) the tracheostomy tube three times; the third event resulted in respiratory distress that led to cardiopulmonary arrest (stoppage of the heart-lung function) and death. On November 4, 2013, the Department received an Entity Self-Reported Incident (CA000375819) that alleged Resident 1 died on September 22, 2013, due to untreated tuberculosis (infectious disease that usually affects the lungs). On December 13, 2013, an investigation was initiated. A review of the admission record indicated Resident 1 was admitted to the skilled nursing facility (SNF) on August 28, 2013, with diagnoses that included chronic respiratory failure, tracheostomy tube, gastrostomy tube (GT, insertion of a feeding tube into the stomach through surgical opening), coronary atherosclerosis (hardening of the arteries that supply blood to the heart), and dementia (disease impairing memory and intellectual functioning). A review of the admission physician's orders dated August 28, 2013, indicated the following: 1. Tracheostomy tube type: Shiley (a particular brand of tracheostomy tube) Size 8. Monitor the placement (trach tie) every shift. 2. Blow by via (warm or cold) mist collar at TM [tracheostomy mask-connected to oxygen delivery tube] 40 % Fio2 (fraction or percentage of inspired oxygen). 3. Hand-held nebulizer treatment 2.5 milligrams (mg) Albuterol and 0.5 mg Atrovent (medications used in the form of inhalation solution to treat breathing problems), respiratory therapist to administer medication over 15 minutes/treatment with hand held nebulizer (a device used to administer medication in the form of a mist) treatment every 6 hours at 8 a.m., 2 p.m., 8 p.m., and 2 a.m. 4. Hand-held nebulizer Pulmicort 0.5 mg every 12 hours (medication used to help breathing). A review of Resident 1's physician Progress Notes dated August 30, 2013, indicated Resident 1 required a tracheostomy for pulmonary hygiene [lung health, keeping the tube/the airway clean and unobstructed with mucous and secretions]. According to the physician's Progress Notes dated September 21, 2013, Resident 1's diagnoses also included chronic obstructive pulmonary disease [COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs] and anemia (red blood cell count is less than normal and the cells in the body do not get enough oxygen). A review of an Admission/Working Care Plan dated August 28, 2013, indicated Resident 1 had a problem related to altered gas exchange requiring use of a tracheostomy tube. The goal of the care plan indicated the airway would remain patent (open) for 30 days. The interventions included to assess respiratory status every shift and as needed; and document abnormal findings and notify the physician. The plan of care did not include interventions to securely anchor the tracheostomy tube to prevent dislodgement accidentally and/or by the resident. According to the Subacute Daily documentation dated September 1, 2013, at 9:40 a.m., Resident 1 was seen and examined by his physician. New orders were written by the physician for tracheostomy culture and sensitivity and for a chest x-ray. A review of the chest x-ray result dated September 3, 2013, indicated Resident 1 had widespread bilateral (both) lung opacities (difficult to see through) present more in the left lung base. This diagnostic result also indicated that this may be due to bilateral pneumonia (lung infection), most severe in the left lung. According to the Minimum Data Set [MDS- a comprehensive assessment and care screening tool], dated September 4, 2013, Resident 1 rarely made himself understood and rarely was able to understand others. The MDS indicted Resident 1 was totally dependent on the facility staff for all his care needs. A review of the Resident 1?s sputum laboratory test results dated September 6, 2013, indicated it was positive for Methicillin/Oxacillin (antibiotics) resistant organism (bacteria resistive to antibiotic treatment). A second diagnostic laboratory culture test the same date, indicated the resident's sputum was positive for mycobacterium tuberculosis complex (bacterial infection). A review of laboratory (lab) blood test results for Resident 1 indicated the resident's oxygen supply was compromised, and the need for uninterrupted oxygen supply as ordered by the physician was vital, as follows: 1. Red Blood Cells (RBC) 2.37 Low (range 4.20 - 5.40 million/ microliter), dated September 9, 2013. 2. Hemoglobin (Hg) 7.2 Critical Low (range 12.0 - 16.0 grams/deciliter), dated September 9, 2013. 3. Hematocrit (Hct) 22.0 Low (range 37.0 - 47.0), dated September 9, 2013. 4. Red Blood Cells (RBC) 2.54 Low (range 4.20 - 5.40 million/ microliter), dated September 16, 2013. 5. Hemoglobin (Hg) 7.3 Critical Low (range 12.0 - 16.0 grams/deciliter), dated September 16, 2013. 6. Hematocrit (Hct) 23.0 Low (range 37.0 - 47.0), dated September 16, 2013. A review of Resident 1?s Respiratory Therapy Notes indicted the following: 1. On September 1 and 2, 2013, secretions were moderate in amount, semi thick and yellow; with rhonchi breath sounds (sounds like snoring or low pitched wheezing caused by accumulation of mucus) that cleared after a breathing treatment. 2. On September 3, 2013, secretions were large in amount, semi thick and yellow; with rhonchi breath sounds that cleared after a breathing treatment. 3. On September 4 - 7, 2013, secretions were moderate in amount, semi thick and yellow; with rhonchi breath sounds that cleared most of the time after a breathing treatment. 4. On September 8 - 10, 2013, secretions were moderate in amount, semi thick and yellow/green in color; with rhonchi breath sounds that remained rhonchi for 5 out of 16 breathing treatments. A review of a plan of care dated September 10, 2013, indicated Resident 1 was at risk for ineffective airway exchange/chest congestion, and shortness of breath secondary to aspiration and respiratory condition secondary to COPD, GT feeding, respiratory failure, tracheostomy tube (trach), and pneumonia. The goal of the care plan was to have effective airway exchange. The interventions on the plan of care included to monitor the resident?s breathing pattern, monitor for presence of chest congestion or increased respiratory distress, and document changes from baseline (normal for this resident), and notify the physician; to monitor for increased secretions; and to monitor oxygen saturation [a relative measure of the amount of oxygen that is dissolved or carried in the body] An oxygen saturation in a range of 96% to 100% is generally considered normal. 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. Kathy Lawrence, MSN, RNBC and Sue Simpson Johnson, BS, RRT Measuring Oxygen Saturation. The plan of care dated September 10, 2013, also did not include interventions to (1) securely anchor the tracheostomy tube to prevent Resident 1 from pulling out the tube, and (2) emergency interventions to be implemented in the event the tube is pulled out. According to the Respiratory Therapy Notes, Resident 1 had pulled out his tracheostomy tube on three occasions as follows: 1. On September 17, 2013, Resident 1 pulled out the tracheostomy tube at 9 p.m., and a new tracheostomy tube was inserted with no complications. The resident's oxygen saturation was 97%. 2. On September 18, 2013, Resident 1 pulled out the tracheostomy tube at 1 a.m. and the tube was re-inserted by the respiratory therapist with no bleeding and no respiratory distress noted. The resident's oxygen saturation was 98%. Following the two incidents of self-decannulation on September 17, and September 18, 2013, the interdisciplinary team (IDT), that included the physician, the respiratory therapist and the licensed nursing staff, did not update Resident 1's plan of care to include interventions useful to prevent self-decannulation such as to properly tie and anchor the tracheostomy tube to assure the resident would not be able to remove the tube. 3. On September 22, 2013, at 11:30 p.m., a review of the Subacute Daily Charting indicated Resident 1 was found with his tracheostomy tube pulled out. The tracheostomy tube was re-inserted, and the resident was noted to be in respiratory distress. Resident 1 was given emergency oxygen via ambu-bag (a device used to provide assisted ventilation to people who are either not breathing or are having trouble breathing) with 100 percent oxygen. Cardiopulmonary-resuscitation [CPR- a lifesaving technique to provide physical breathing and pumping of the heart] was initiated due to Resident 1?s lack of a pulse. On September 22, 2013, at 11:35 p.m., paramedics were called. At 11:40 p.m., paramedics arrived and took over the care. At 11:48 p.m., Resident 1 was pronounced dead. The physician's order to treat Resident 1's medical conditions, such as chronic respiratory failure and pneumonia, by administering oxygen and medications, was disrupted each time Resident 1 self-decannulated, causing disruption in his breathing which led to oxygen deprivation. On September 18, 2015, at 12:30 p.m., during an interview the Respiratory Therapy Director (RTD) stated that there was no way to tell when a resident is going to pull out the trach tube. According to RTD, there was no alarm to alert the staff when Resident 1 pulled out his tracheostomy tube. RTD stated on September 22, 2013, Resident 1 was observed at 11:15 p.m., before the trach tube was pulled out. At 11:30 p.m., the resident was observed with the tracheostomy tube pulled out. The RTD stated he would not question this because, "It was not like a two hour gap between observations, it was only 15 minutes." According to the RTD, this meant that the respiratory therapist (RT) was making his rounds. The RTD confirmed that Resident 1's plan of care had not been updated since the resident first pulled out his trach tube, with alternate interventions to prevent self-decannulation. The RTD stated this was the responsibility of the RTs and nursing licensed staff. On September 18, 2015, at 1:25 p.m., during an interview, RT 2 stated residents with tracheostomy tubes are supposed to be monitored by visual checks by the RTs, nursing, and certified nursing assistants. RT 2 stated in the past, it was the facility's practice to monitor a resident with a history of self-decannulation by sitting in front of the resident and continuously monitoring a resident (one-on-one) this way. RT 2, when asked, did not know if this was the facility's protocol or if individual staff members would take it upon themselves to monitor a resident in this manner. On September 18, 2015 at 2:30 p.m., during another interview, the RTD stated Resident 1's care plan had not been updated and there was no protocol put in place. During the interview, RTD stated someone should have been assigned to Resident 1 for one-to-one monitoring as soon as possible after the first self-decannulation incident. The RTD stated this incident with Resident 1 could have been avoided. On September 18, 2015, at 2:55 p.m., the Director of Nursing (DON) stated that it was a standard practice to have a sitter assigned (one-to-one monitoring) to residents who self-decannulate, and an assessment should be done to determine if there is an underlying reason why the resident manifests the behavior of pulling out the tracheostomy tube. The DON stated one-to-one monitoring should have been assigned to Resident 1, and the plan of care should have been updated and individualized to include one-to-one monitoring activities. According to the facility's revised policy dated January 1, 2012, titled "General Documentation Policy," the care plans shall be reviewed and revised at a minimum of quarterly or more often as the resident's condition warrants and in accordance with State and Federal Regulations. The facility's undated policies and procedures regarding ?Tracheostomy Care? provided by the DON did not address precautions on how to prevent residents from pulling out a tracheostomy tube. According to the Certificate of Death, Resident 1's immediate causes of death included: (A) Cardiac Arrest (sudden stop in effective blood circulation due to the failure of the heart to contract effectively); and (B) Myocardial Infarction (heart attack). The facility failed to ensure that Resident 1, who had a tracheostomy tube, received proper respiratory and tracheostomy care and services to prevent repeated self-decannulation, including but not limited to, failure to: 1. Ensure Resident 1, who had exhibited a behavioral pattern of pulling out his tracheostomy tube, was continuously monitored to prevent him from this behavior. 2. Ensure Resident 1?s tracheostomy tube was securely tied to prevent repeated self-decannulation. 3. Ensure Resident 1?s plan of care was updated to include interventions necessary to prevent self-decannulation of the tracheostomy tube in accordance with the facility?s protocols, including continuous one-to-one monitoring, and an equipment alarm to alert the staff without a delay if self-decannulation occurs. As a result, Resident 1 pulled out the tracheostomy tube three times; the third event resulted in respiratory distress that led to cardiopulmonary arrest and death. 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 Resident 1?s death. |
| 920000067 |
TARZANA HEALTH AND REHABILITATION CENTER |
920012654 |
A |
27-Oct-16 |
OD9211 |
8697 |
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 3/16/16, at 12:50 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Resident 1 sustaining a fall at the facility resulting in injuries to the right knee and the head which required hospitalization and surgery. Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and failed to ensure Resident 1, who had history of falls, had muscle weakness, difficulty walking, and was a smoker, was provided with supervision, assistance, and an environment free of accident hazards as possible to prevent fall and injuries, including: 1. Failure to evaluate accident risks and hazards to prevent falls and minimize injury. 2. Failure to accurately assess the resident?s tobacco use and smoking habits upon admission in order to develop a plan of care with interventions to promote the resident?s safety. 3. Failure to provide the necessary supervision and assistance with transfers and walking as indicated in the plan of care. As a result, on 2/29/16, five days from admission to the facility, Resident 1 sustained an unwitnessed fall, when returning to her room from the smoking designated area, with injury to the head and the right knee. Resident 1 required immediate transfer to a general acute care hospital (GACH) where she underwent head surgery due to subdural hemorrhage (blood vessels bleeding, usually veins, that rupture between the brain and the outermost of three membrane layers that cover the brain) and can be life-threatening). A review of Resident 1's admission record (face sheet) indicated the resident was admitted from a GACH on 2/24/16, with a diagnosis of syncope (temporary loss of consciousness), abnormalities of gait and balance, and muscle weakness. According to the discharge records from the GACH, the History and Physical examination dated 2/16/16 indicated Resident 1 was admitted to the GACH on 2/16/16 with weakness and had fallen at home. The social history indicated for the smoking status, the resident was a daily smoker of 0.25 packs for 10 years. On admission to the GACH a computed tomography (CT ?radiologic study) scan of the brain was performed which indicated no acute changes noted and a small left hygroma (collection of cerebrospinal fluid without blood. Most often derived from chronic subdural hematomas). A review of the facility?s Nursing Admission Data Collection forms dated 2/24/16 indicated Resident 1 was alert, oriented, able to verbally communicate her needs, required supervision oversight or cueing during transfers, and was not a smoker. The form did not contain information addressing the resident?s ability to walk, the level of assistance required, and/or the use/need of assistive devices (such us walker, cane, wheelchair) during transfers, locomotion, and ambulation. A plan of care developed on 2/25/16, for Resident 1?s need of assistance with activity of daily living (ADLs) related to weakness and history of falls, muscle weakness, difficulty walking, and recent decline in function, had a goal for the resident to be assisted with ADLs daily for 30 days. Another goal was for the resident to improve with ADLs with nursing and physical/occupational therapy interventions. The intervention included assisting the resident with ambulation in room or corridor as needed; assisting the resident to move around the unit/facility as needed; reminding resident ?safety first;? and encouraging independence but with safety precautions. There was no plan of care developed for the resident?s smoking habit, to indicate the necessary supervision to ensure Resident 1?s safety. Further record review indicated that on 2/29/16, at 11:20 a.m., Resident 1 had an unwitnessed fall when returning from the smoking area. Resident 1 tripped by the door and hit the right side of her head with the edge of the door and had also a right knee abrasion (wound with damage to the skin). On the same day, the physician ordered the resident to be transferred to a GACH for further evaluation. A review of the GACH emergency department (ED) notes dated 2/29/16, indicated Resident 1 stated she lost her balance, fell, and hit the right side, back of her head, injured her right knee and was complaining of a mild dull headache. Under Diagnosis and Medical Decision Making, the note indicated Resident 1 had a ground level fall with large, left sided acute subdural hemorrhage and immediate consultation was obtained with neurosurgery, with plans to take Resident 1 to the operating room the next day. A review of the post-operative notes dated 3/1/16, indicated Resident 1 had a craniotomy (surgical opening of the skull) due an acute left frontal subdural hemorrhage. Resident 1 remained in stable condition until discharge from the GACH back to the facility on 3/7/16. On 3/16/16, at 5 p.m., during an interview, Resident 1 stated she fell (on 2/29/16) coming from the smoking area and the door closed on her. Resident 1 stated the nursing staff accompanied her to the smoking area for about a day or two from admission, and then determined she no longer needed supervision, because she was alert, oriented, and independent. The facility policy and procedure titled, "Standards of Nursing Practice," revised 12/2005, indicated under Assessment - the nurse collects data regarding the resident's current health status and potential risk areas. Data was obtained through direct resident assessment and health history, as well as interaction with family members and other healthcare providers. A review of the facility policy titled, "Safe Smoking," dated 11/ 2011, indicated the interdisciplinary team members determine if a resident was a safe or unsafe smoker before the resident exercised the privilege to smoke. An evaluation was conducted for all smokers upon admission. The policy indicated the resident's care plan would reflect the resident was a smoker, the degree of supervision necessary, and the education and options for smoking cessation activities that were offered to the resident. The policy indicated all unsafe smokers should be supervised at all times. During an interview with the social worker (SW) on 3/17/16, at 11:40 a.m., the SW stated she did not complete a safe smoker assessment or a smoking plan of care for Resident 1, because the nursing initial admission assessment indicated Resident 1 was a non-smoker. During an interview with the Director of Nursing (DON), on 3/17/16, at 2 p.m., the DON stated the charge nurse was responsible for completing the admission assessment. The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being and failed to ensure Resident 1, who had history of falls, had muscle weakness, difficulty walking, and was a smoker, was provided with supervision, assistance, and an environment free of accident hazards as possible to prevent fall and injuries, including: 1. Failure to evaluate accident risks and hazards to prevent falls and minimize injury. 2. Failure to accurately assess the resident?s tobacco use and smoking habits upon admission in order to develop a plan of care with interventions to promote the resident?s safety. 3. Failure to provide the necessary supervision and assistance with transfers and walking as indicated in the plan of care. As a result, on 2/29/16, five days from admission to the facility, Resident 1 sustained an unwitnessed fall, when returning to her room from the smoking designated area, with injury to the head and the right knee. Resident 1 required immediate transfer to a GACH where she underwent head surgery due to subdural hemorrhage. The above violation presented either (1) imminent danger that death or serious harm to the resident of the Skilled Nursing Facility would result therefrom, or (2) substantial probability that death or serious physical harm to the resident of the Skilled Nursing Facility would result therefrom. |
| 940000015 |
The Orchard - Post Acute Care |
940009543 |
A |
19-Nov-12 |
DVDQ11 |
11040 |
F-323 483.25 (h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 6/22/12, at 8:40 a.m., an unannounced visit was made to the facility to investigate an entity reported incident and a complaint related to Resident 1?s quality of care. Based on observation, interview and record review, the facility failed to ensure Resident 1, who was assessed as requiring extensive assistance and two or more person physical assist with transfer, received the necessary assistance and assistive device by failing to: 1. Provide two persons assist during transfer from wheelchair to bed as assessed. 2. Ensure staff used a gait belt during transfer for safety as per policy. On 4/7/12, Resident 1, while being manually transferred by one person, Certified Nursing Assistant 1 (CNA 1), from the wheelchair to bed, fell onto the floor on her knees and on 4/9/12, was diagnosed with a right hip fracture. The fracture could not be surgically repaired, requiring pain management and resulted in a decline in the resident's functional status.On 6/22/12, a review of the clinical record revealed the resident was a 99 years old female originally admitted to the facility on 12/22/08, with diagnoses that included status post right hip fracture, right hemiarthroplasty (surgical repair involving replacement of the head of the femur with a prosthesis), hypertension, osteoporosis (a disorder characterized by abnormal loss of bone tissue, with an increase fracture risk) and diabetes mellitus. The Minimum Data Set (MDS - standardized assessment and care planning tool) dated 3/12/12, indicated the resident had memory problems, was able to communicate, had no mood or behavioral problems, required extensive assistance with two or more person physical assist during bed mobility, transfer and locomotion, and required extensive assistance and one person physical assist with walking, eating, personal hygiene and bathing. The resident was assessed as having an unsteady balance during walking, moving from seated to standing position and surface-to-surface transfer. The resident did not have functional limitation on the range of motion (ROM) on the lower extremities. The resident used a walker and a wheelchair as mobility devices and was frequently incontinent of bladder function and occasionally incontinent of bowel function. The plan of care dated 3/16/12, was developed for the resident's activities of daily living (ADLs) deficit with need of assistance or dependence in bed mobility, transfer, locomotion and walking, poor safety judgment, unsteady gait, limited endurance and balance problems. The goal with a target date of 6/14/12, was for the resident to maintain the existing ADL self-performance level and the approaches included to provide assistance with ADL care as needed and provide the appropriate level of assistance to promote safety. Another plan of care dated 3/16/12, developed for the resident's risk of fracture and injury related to osteoporosis had a goal with a target date of 6/14/12, for the resident not to experience any fracture/injury. The approaches included to give the medication (Fosamax) as ordered and to assist the resident as needed. A Fall Risk Assessment completed on 3/14/12, documented the resident was at high risk for falls. A physician's order for restorative nursing assistant (RNA) program dated 2/13/12, indicated for the RNA to ambulate the resident with a front wheel walker as tolerated five times a week. According to the RNA?s notes for the month of 3/2012 and from 4/1/12 to 4/7/12, the resident was able to walk approximately 15 feet with maximum assistance. The physician's order included administration of a pain narcotic medication, Percocet (oxycodone with acetaminophen) 5-325 milligrams (mg) orally every four hours as needed for moderate pain and two tablets for severe pain.According to a Change In Condition Report - Post Fall/Trauma dated 4/8/12, the resident had a fall incident in her room on 4/7/12, at 8:30 p.m., and complained of pain rated 8 over 10 (8/10 - pain rating scale from zero to 10, zero indicating no pain and 10 indicating the worst possible pain) on the right knee. The physician was informed and ordered a stat (immediate) x-ray to the right knee. The x-ray result dated 4/7/12, taken at 10:52 p.m., and reported to the physician on 4/8/12, at 6:55 a.m., indicated no fracture on the right knee.On 4/9/12, timed at 10:32 a.m., a nursing note indicated the resident was identified with swelling to the right thigh, had severe pain and was unable to move the leg. The physician was informed and ordered an x-ray of the right hip at 11:30 a.m. At 3 p.m., the x-ray result reported a right femoral shaft (body of the femur) fracture. The result was relayed to the physician, who ordered the resident to be transferred to an acute care hospital for further evaluation. At 4:20 p.m., the nursing note documented the resident was transferred to the hospital via ambulance.The x-ray result of the right knee dated 4/9/12, indicated a femoral shaft fracture overlying the stem of a hip prosthesis.The bones were moderately osteopenic (a condition of subnormal mineralized bone) and the fracture appeared acute or subacute. According to the nursing notes, the Pain Assessment Flowsheet and the medication administration record (MAR) from the time of the fall (4/7/12 at 8:30 p.m.) to the time of transfer (4/9/12 at 4:20 p.m.) approximately 46 hours, the resident complained of right knee/leg pain rated from 6/10 to 8/10 and two tablets of Percocet were administered seven times.According the acute care hospital Physician Progress Notes form dated 4/11/12, the resident was unlikely to survive a surgery. The plan was to immobilize the resident and give pain medications. The resident returned to the facility on 4/12/12, three days later, with orders for pain management.According to the facility?s attending physician's progress note dated 4/13/12, the resident had a mechanical fall, fractured the right proximal femur, was sent to the hospital but was not a candidate for an operation and was sent back with pain medications. The significant change in status MDS assessment dated 4/27/12, revealed the resident was no longer ambulatory and had ROM limitation on both lower extremities.A review of the Pain Assessment Flowsheet, MAR and nursing notes revealed the resident manifested pain to the right leg/thigh almost daily since she was readmitted to the facility on 4/12/12 to 7/13/12, not including 4/15/12 through 4/20/12, when the resident was in the acute care hospital secondary to a low oxygen saturation (low oxygen level in the blood) and returned with diagnosis of pneumonia and an order for the narcotic medication Morphine Sulfate 2 mg intravenous (IV) as needed every four hours for severe right hip pain which was discontinued on 5/29/12. From 4/21/12 to 5/28/12, (excluding 5/20/12 and 5/24/12 -5/27/12) the resident received daily IV Morphine for severe right hip pain (8-10/10).For the month of 6/2012, the resident was medicated 20 times for severe pain (8-10/10) and three times for moderate pain (4-7/10).For the month of 7/2012 the resident received Percocet two tablets for 6/10 and 8/10 pain to the right leg five times. According to the facility's Incident Investigation Form, Summary of Investigation dated 4/9/12, on 4/7/12 at 8:30 p.m., a CNA (CNA 1) assisted the resident from the wheelchair to the bed manually. The resident was able to stand up, but lost her balance while being held by the CNA. The CNA lowered the resident down on the floor on her knees. The resident also hit her head against the closet at the time.The facility's policy and procedure on Safe Transfer of a Resident dated 5/2007, indicated gait belts are assistive devices used to help ensure the safety of the resident and staff during transfers and ambulation. The procedures included to use the gait belt for all transfers if a gait belt was not contraindicated. The facility's investigation report and the clinical record did not address the use or lack of use of a gait belt during the transferring procedure that led to the resident?s fall on 4/7/12.A review of the CNAs? documentation from 3/20/12 to 4/7/12, revealed seven out of 38 times the resident was transferred with only one person physical assist.On 7/13/12, at 8:30 a.m., during an interview, the director of nursing stated after a fall on the knees an x-ray should include the hip especially with a resident with a history of hip fracture. On 7/13/12, at 10:40 a.m., during an interview, RNA 1 stated prior to the fall, the resident was walking with a walker and two persons assistance.On 7/13/12, at 11:42 p.m., the resident was observed in her room sitting in a wheelchair. Registered Nurse 1 (RN 1), CNA 2 and a Family Member 1 were present in the room. The resident complained of severe pain (9/10) on the right thigh and leg. She was crying and stated she could not stand it. The right knee had greenish/bluish discoloration. CNAs 2 and 3 proceeded to transfer the resident from the wheelchair to the bed using a mechanical lift.On 7/13/12, at 12:23 p.m., during an interview, Family Member 1 stated he visits the resident twice daily for lunch and dinner and prior to the fall, the resident was able to go to the bathroom and use the sink to wash her hands with the assistance of the nursing staff; however, after the fall incident, the resident was no longer able to use the bathroom.On 7/13/12, at 3:10 p.m., during an interview, RN 2 stated the CNAs were aware of the use of a gait belt during all transfers.A review of CNA 1?s personnel file revealed a date of hire of 3/22/12, and was terminated on 4/13/13, due to failure to follow facility?s policy and procedures. Three attempts were made to contact CNA 1 by telephone but there was no answer and messages were not returned.The facility failed to ensure Resident 1, who was assessed as requiring extensive assistance and two or more person physical assist with transfer, received the necessary assistance and assistive device by failing to: 1. Provide two persons assist during transfer from wheelchair to bed as assessed. 2. Ensure staff used a gait belt during transfer for safety as per policy. On 4/7/12, Resident 1, while being manually transferred by one person, CNA 1, from the wheelchair to bed, fell onto the floor on her knees and on 4/9/12, was diagnosed with a right hip fracture. The fracture could not be surgically repaired, requiring pain management and resulted in a decline in the resident's functional status. The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 1. |
| 940000015 |
The Orchard - Post Acute Care |
940009609 |
A |
20-Nov-12 |
6P8211 |
13582 |
CFR 485.25(h) Accidents. The facility must ensure that- (1) The resident environment remains as free as of accidents hazards as is possible. (2) Each resident receives adequate supervision and assistance devices to prevent accidents. The Department received an entity reported incident (ERI) on 10/26/12, alleging a resident (Resident 1) complained of pain on the right elbow during care. On the day of the incident (10/21/12) Resident 1 reported hearing a crack in her right arm, while being lifted by a mechanical lift (SARA lift) by two certified nurse assistants (CNA) and felt pain. According to the report, after an assessment of Resident 1's right arm, the right arm was swollen with pain and the resident was unable to move the right arm. The medical doctor (MD) was notified, Dilaudid (narcotic pain medication) was given for pain, and an x-ray was ordered, and the right arm was placed in a sling. On 10/30/12, at 2:05 p.m., an unannounced complaint investigation was conducted. Based on observation, interview, and record review, the facility failed to maintain a hazard free environment for Resident 1, who had weakness, muscle wasting, contractures, tremors due to Parkinson?s disease and was unable to bear weight. The facility failed to: 1. Evaluate if the SARA lift was suitable for Resident 1. 2. Follow Resident 1's plan of care, which indicated a two-person assist was required for bed mobility and transferring. 3. Adhere to the resident's and family member's requests to not use a SARA lift to transfer the resident. 4. Stop the lift transfer after the resident repeatedly requested the staff to stop the lift because her arm was breaking. These failures of Resident 1 not being suited for the use of the Sara lift, which resulted in Resident 1 sustaining a displaced right humerus (upper arm) spiral fracture (bone twisted and broken), being admitted to a general acute care hospital (GACH) for four days, and transferring to another skilled nursing facility (SNF) per the family's request.On 10/30/12 at 2:05 p.m., during an initial tour of the facility, Resident 1's roommate (Resident 2), who was alert and oriented, stated on the date of the incident (10/21/12) Resident 1 was being transferred and was afraid. She stated she heard the CNAs say, "Put your arms in and be still." Resident 2 stated she heard a noise then the resident state, "You broke my arm." Resident 2 stated the resident (Resident 1) would often cry out with pain in her legs. On 10/30/12, at 2:40 p.m., the CNA that transferred the resident (CNA 1) was interviewed. CNA 1 stated on 10/21/12, the resident requested to go to the bathroom. She stated she got the resident up out of bed by herself to the edge of the bed, and placed the SARA lift straps around the resident's waist, although the resident required a two-person assist in bed mobility and transferring. CNA 1 stated she asked the housekeeper to go get help to transfer the resident. CNA 2 came to assist CNA 1 in transferring the resident. CNA 1 stated Resident 1 complained of right arm pain after the transfer. CNA 1 stated she noticed the resident's right arm was "deformed? and called the charge nurse.On 10/30/12 at 2:55 p.m., during an observation, CNA 1 demonstrated how the SARA lift was used to transfer the resident in the presence of the director of staff development (DSD). According to the observation, the lift required a resident to have a firm grip on the hand rails; use upper and lower body strength, bear weight; have a good range of motion; and maintain posture during the transfer. On 10/30/12, at 3:07 p.m., the facility's rehabilitation director was interviewed. He stated on 10/8/12, Resident 1 was started on physical therapy (PT) due to muscle weakness and difficulty in walking. The director stated the Hoyer lift (mechanical lift) should be used for residents with osteoporosis (weak bones) and the SARA lift (mechanical lift) should not be used for non-weight bearing residents with contractures. A review of the PT evaluation and certification report for the time period of 10/9/12-11/6/12 indicated the resident was totally dependent in: bed mobility; transfers; gait and had impaired range of motion (ROM) for lower extremity (LE); poor balance with support while sitting or standing; Upper extremity support and was unable to weight shift. According to the SARA lift manufacturer's manual, dated 2011, "A resident must be able to support the majority of their own weight, otherwise injury may occur."A review of Resident 1's Admission Face Sheet on 10/30/12, at 3:30 p.m., indicated the resident was an 84 year old female who was admitted to the facility on 3/3/10, with diagnoses including: abnormality of gait (walking); disuse atrophy (decrease in size of a normally developed organ or tissue) muscular wasting; Type 2 diabetes (high blood sugar), and bilateral hip replacement.On 10/30/2012, a review of the Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/12/12, indicated Resident 1 was alert and oriented with clear speech and was able to communicate. According to the MDS, the resident required a two-person assist in transferring and all activities of daily living (ADL). The resident had functional impairment of both the upper and lower extremities on both sides.A review of a Fall Risk Assessment, dated 10/9/12, indicated the resident had a total score of 18 (a total score above 10 represents high risk for falls). The assessment, under gait/balance, indicated the resident had a low score for balance in standing and walking, and had jerking movements. A review of a care plan, dated 4/2/12, the resident's risk for injury/fall, indicated the resident had potential for injury/fall due to her poor balance, limited mobility, lack of awareness, Parkinson's disease, and sensory deficits. The staff's plan of approach included assisting the resident as necessary with a two-person assist in care and transferring. The facility's investigation report, dated 10/21/12 and timed at 10:30 a.m., indicated the resident sustained an injury to her right arm during transfer resulting in severe pain and swelling. Due to the worsening of the right arm pain, at 4:30 p.m., the same day, the resident was transferred to the emergency room per the physician's orders.A review of the GACHs' records on 10/31/12 indicated the resident was seen at 3:30 p.m., complaining of severe right arm and elbow pain with deformity. An x-ray was ordered upon admission. The x-ray report from the GACH, dated 10/21/12, indicated the resident had a displaced spiral fracture of the distal right humerus, approximately two centimeter overriding with the distal bony fragment displaced medially. According to OrthoPod.com, a spiral fracture is also called a torsion fracture, can only be caused when a limb (arm or leg) is twisted in such a way that causes the bone to break. The resident was admitted to the GACH for four days for pain management and orthopedic treatment. Resident 1 was discharged to another skilled nursing facility (SNF) on 10/24/12.On 10/30/12, at 4:06 p.m., during an interview, the director of nursing (DON) stated a complete investigation of the incident was conducted by interviewing Resident 1, CNA 1, CNA 2, and the charge nurse (LVN 1). The DON stated Resident 1's fracture occurred during a transfer on the SARA lift. The DON stated she was unaware of the resident having fear while using a SARA lift and had requested for the SARA lift to not be used for her transfer. The DON stated licensed nurses decides which lift (Hoyer or SARA) is to be used for each resident.On 10/31/12, at 9:10 a.m., Resident 1's other roommate (Resident 3 ), who was alert and oriented, was interviewed and stated she heard the resident scream "My arm!, My arm!" but she could not see the resident since the curtains were drawn. At 10/31/12, at 10:50 a.m., a telephone interview was conducted with CNA 2. She stated she was called to Resident 1's room by a housekeeper. CNA 2 stated the resident already had the SARA lift straps on and was sitting on the bed when she arrived to the room. CNA 2 stated she held the shower chair while the resident was transferred to the shower chair. CNA 2 stated the resident then complained of pain, but still wanted to go to the bathroom.A telephone interview was conducted with the resident's family member on 10/31/12, at 11:10 a.m. She stated she attended an interdisciplinary meeting (IDT) in September 2012, and requested for the facility to stop using the SARA lift to transfer the resident because Resident 1 did not like it and was afraid. On 10/31/12 at 12:08 p.m., during a telephone interview, the registered nurse (RN 1), who was in charge the day of the incident, stated Resident 1 told her she heard her right arm crack while on the SARA lift and she had severe pain. RN 1 stated she called the MD and an x-ray was ordered and Dilaudid was given. She stated although the x-ray was read as no fracture initially, the resident continued to have severe pain. RN 1 stated the resident still had severe pain after being medicated for pain, so she called the MD again. The MD ordered to transfer the resident to the GACH for further evaluation. During an interview, on 10/31/12, at 1:40 p.m., a licensed vocational nurse (LVN 1) stated she was called to Resident 1's room to assess the resident's right arm after the incident on 10/21/12. LVN 1 stated, "The resident's arm was swollen with two bumps (displaced fracture) and bent while the resident complained of pain." On 10/31/12 at 3:30 p.m., Resident 1 was interviewed and a declaration obtained at another SNF where the resident was transferred after discharge from the GACH on 10/24/12. Resident 1 was observed to be in distress and verbalizing pain in the right arm, which was her dominant arm. The right arm was in an open cast (fracture brace) and a sling. The resident's hands had bilateral contractures and the resident was observed to have constant whole body tremors (Parkinson's disease). The resident was asked if she could grip a cylindrical cup. The resident attempted to grab the cup, but was unable to grab the cup due to the contractures in the hands and the tremors from Parkinson's disease. On 10/31/12 at 4:10 p.m., Resident 1 was asked if she remembered what happened to her right arm. She stated while at the other facility she had called for help to go to the bathroom and CNA 1 got her up and placed her on the edge of the bed. The resident stated CNA 1 placed the SARA strap around the waist. The resident stated, "I told them I did not want to use that lift days before the incident, but they did not listen. My family even told them not to use it, but they told me they use it to protect themselves, not me." Resident 1 stated you have to put your hands like you are going to catch a ball then the lift is supposed to lift you in an upright (standing) position. Resident 1 stated it was hard to put her hands on the bar and lift. Resident 1 stated when the CNA pulled the Sara lift?s cord, it hurt, but she continued to pull the cord and, ?I told her to stop three times and told her you broke my arm. She did not do anything, but was supposed to stop to see what happened." Resident 1 stated, "If I tell you to stop and not keep going then you should stop, and see what happened. I think this injury could have been prevented. " On 11/2/12 at 12:10 p.m., during a telephone interview, Resident 1's MD stated he was notified of the resident's injury while using a SARA lift. He stated he was not familiar with the SARA lift, but stated he could see how the fracture could occur using a lift because the resident was very weak and could not stand on her own. During a subsequent transfer demonstration of the SARA lift, in the presence of the facility?s staff on 11/2/12 at 1:10 p.m., CNA 4 demonstrated on CNA 5 how to lift and transfer a resident. CNA 5 had to tell CNA 4 to pull the belt tighter. CNA 5 was observed, and stated it required a firm grip to hold onto the lift and upper body strength to maintain her balance during the transfer.During the demonstration, CNA 3 stated Resident 1 had complained several times that she did not want to use the SARA lift. CNA 3 was asked if it was reported and she stated, "Yes, the charge nurses were made aware." CNA 4 stated Resident 1's hands were always cold, so she would wear gloves and her legs were stiff and painful. CNA 4 stated, "The resident was unable to walk or grip with hands." On 11/2/12 at 2:55 p.m., RN 2 stated, "The resident have to be able to hold on the SARA lift and use some weight bearing." RN 2 stated the decision to use a SARA lift was a nursing judgment of the residents? strength. RN 2 stated if a resident says to stop, the CNA should stop and see what happened and call the charge nurse. The facility failed by not: 1. Evaluating if the SARA lift was suitable for Resident 1. 2. Following Resident 1's plan of care, which indicated a two-person assist was required for bed mobility and transferring. 3. Adhering to the resident's and family member's requests to not use a SARA lift to transfer the resident. 4. Stopping the lift transfer after the resident repeatedly requested the staff to stop the lift because her arm was breaking. 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. |
| 970000021 |
THE REHABILITATION CENTER ON LA BREA |
940009723 |
B |
30-Jan-13 |
83PF11 |
7773 |
F-323 483.25 (h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. On 7/30/12 at 1:10 p.m., an unannounced visit was made to the facility to investigate complaints regarding pharmaceutical services and quality of care.Based on observation, interview and record review, the facility failed to provide supervision and maintain an environment free of accident hazards by licensed nurses failing to: 1. Lock the medication cart before leaving the cart unattended. 2. Secure a set of keys that allowed access to the medication cart, the medication room, the medical supply room, the fire alarm box, and two exit doors. Resident 2 obtained seven medication bubble (blister) packs (package consisting of a clear plastic overlay affixed to a cardboard backing for protecting and displaying each individual medication dose) and kept them for two weeks when the medication cart was left unlocked and unattended. Also, Resident 2 took a set of five keys when they were left unattended on top of a medication cart. The keys allowed access to the medication cart, the medication and supply rooms, the fire alarm box and two exit doors. Resident 2 kept the five keys for two months. This deficient practice resulted in unauthorized access to medications and supplies, which posed a risk for other unauthorized individuals (residents, staff or visitors) to gain access to medications and could result in inability of the staff members to access the fire alarm in the event of fire.On 7/30/12 at 3:40 p.m., during an interview, Resident 2 showed the Evaluator seven bubble packs of medications and a set of five keys. The resident stated he knew nurses should keep medications locked to prevent people from getting medications; however, he had noticed the nurses were not careful with safeguarding the medications and he wanted to teach them a lesson. The resident stated approximately two weeks ago, Licensed Vocational Nurse 3 (LVN 3) left the medication cart open and unattended so he took some bubble packs but later returned them to LVN 3. Then, approximately two weeks ago, he observed another nurse, LVN 2, leaving the medication cart open and unattended. He then took the seven bubble packs but this time he kept them.The seven bubble packs consisted of the following:1. One pack of Warfarin, an anticoagulant, for Resident 3. 2. Two packs of Metoprolol, a medication to treat high blood pressure, and one pack of Singulair, a medication to prevent asthma attacks, for Resident 4. 3. One pack of Furosemide, a medication to treat excess fluid, for Resident 5; and two packs of Amiodarone, a medication to treat abnormal heart rhythm, for Resident 5. During the course of the interview, Resident 2 added he had observed on two occasions the nurses leaving unattended a set of keys on top of the cart that they used to open the cart and the medication room and he knew that was inappropriate since anybody could get hold of the keys. The resident stated on the two occasions he took the keys but gave them back to the nurses when they were looking for them. However, on the third occasion, two months ago, he took the unattended set of keys and did not give them back. At the end of the interview, Resident 2 gave the set of keys and medications to the Evaluator. At 4:20 p.m., when the director of nursing (DON) was presented with the seven medication bubble packs and the set of keys, he stated he was not aware Residents 3, 4 and 5 were missing medications or that a set of keys was missing. The DON stated the licensed nurses should always lock the medication cart and keep the keys with them. The DON indicated one key was for the medication cart, one key for the medication room, one key for the supply room, one key for the fire alarm box, and one key for two exit doors. The DON stated the nurses should have reported to him the missing keys and missing medications. On 7/31/12 at 3:10 p.m., during an interview, LVN 2 acknowledged he left the medication cart open on one occasion and saw Resident 2 opening the cart but he did not see the resident take anything.A review of Resident 2's clinical record indicated the resident was a 54 years old male, admitted to the facility on 5/8/12, and re-admitted on 1/2/12, with diagnoses including ulcerative colitis, attention to ileostomy (a surgical procedure in which the small intestine is attached to the abdominal wall in order to bypass the large intestine; digestive waste then exits the body through an artificial opening called the stoma) and anxiety. According to the annual Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 5/4/12, the resident had no memory problems, was able to make his needs known and understand others and was independent in performing his activities of daily living (ADLs). A review of Resident 3's clinical record indicated the resident was admitted to the facility on 7/10/12, with diagnoses including atrial fibrillation (abnormal heart rhythm). The resident was assessed as sometimes was able to make her needs known and understand others and required limited to extensive assistance with ADLs. A physician?s order dated 7/13/12 indicated Coumadin (generic name is warfarin) 3 mg (milligrams) by mouth daily at 5 p.m. A review of Resident 4's clinical record indicated an admission to the facility dated 3/16/12, with diagnoses including hypertension (high blood pressure), asthma and chronic obstructive pulmonary disease (COPD). The resident had physician?s orders dated 4/24/12, for Metoprolol 50 mg via gastrostomy tube (GT - a tube surgically inserted into the stomach through an abdominal wall for administration of food, fluids, and medications) twice a day with meals for hypertension and an order for Singulair 10 mg via GT every night at bedtime for COPD. A review of Resident 5's clinical record indicated an admission dated 7/17/12, with diagnoses including congestive heart failure (CHF) and hypertension. The admission physician?s orders included Lasix (generic name is furosemide) 40 mg by mouth every 12 hours and Amiodarone 400 mg by mouth three times a day.On 7/31/12, at 3 p.m., after reviewing the medication administration record (MAR) for Residents 3, 4 and 5, with the DON, it was determined the residents did not miss their ordered medications because the missing medications had been reordered from the pharmacy. The facility failed to provide supervision and maintain an environment free of accident hazards by licensed nurses failing to: 1. Lock the medication cart before leaving the cart unattended. 2. Secure a set of keys that allowed access to the medication cart, the medication room, the medical supply room, the fire alarm box and the emergency exits locks. Resident 2 obtained seven medication bubble (blister) packs and kept them for two weeks when the medication cart was left unlocked and unattended. Also, Resident 2 took a set of five keys when they were left unattended on top of a medication cart. The keys allowed access to the medication cart, the medication and supply rooms, the fire alarm box and two exit doors. Resident 2 kept the five keys for two months. This deficient practice resulted in unauthorized access to medications and supplies, posed a risk for other unauthorized individuals (residents, staff or visitors) to gain access to medications and could result in inability of the staff members to access the fire alarm in the event of fire. The above violation had the direct or immediate relationship to the health, safety, or security of the residents. |
| 970000021 |
THE REHABILITATION CENTER ON LA BREA |
940009724 |
B |
30-Jan-13 |
83PF11 |
11311 |
F - 309 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. On 7/30/12 at 1:10 p.m., an unannounced visit was made to the facility to investigate a complaint regarding pharmaceutical services and quality of care.Based on interview and record review, the facility failed to provide Resident 1 with the necessary care in accordance with the assessment, plan of care, and facility's policy and procedure by nursing staff failing to: 1. Monitor the vital signs and oxygen saturation level after the resident was identified with a change of condition manifested by shortness of breath and low oxygen saturation [the amount of oxygen bound to hemoglobin (protein in the red blood cells) expressed as a percentage of the maximum binding capacity of 100%] after oxygen was administered. 2. Contact the attending physician for further instructions regarding the care of the resident as stated in the plan of care and the facility?s policy and procedure. On 7/12/12, at 9:10 a.m., during a physical therapy session, Resident 1 became short of breath and had an oxygen saturation of 77% at room air (without the use of oxygen). After the resident's sudden change of condition, initial assessment and intervention, the resident?s vital signs and oxygen saturation were not further monitored for 15 minutes to evaluate the resident's response to the oxygen intervention and the resident's attending physician was not contacted for further instructions. As a result, the resident was evaluated at the emergency room (ER) at 10:17 a.m. one hour and seven minutes after the change of condition was assessed.A review of the closed clinical record indicated Resident 1 was admitted to the facility on 7/3/12 with diagnoses that included pneumonia, tachycardia (abnormal rapid heart rate), hypertension (high blood pressure), diabetes mellitus [the body cannot use the sugar (glucose) normally], and status post left knee arthroplasty revision (knee replacement). On 7/12/12, nine days after admission, the resident was transferred to a general acute care hospital (GACH) via 911 where she died upon arrival due to cardiac arrest. According to the Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 7/10/12, the resident was able to make her needs known, was able to understand others, and required limited to extensive assistance with activities of daily living (ADLs).According to a plan of care developed on admission for the resident's risk for cardiac distress related to the diagnoses of tachycardia and hypertension, the interventions included to monitor for headache, chest pain, irregular pulse, edema, shortness of breath, elevated blood pressure, dizziness, hypotension, altered level of mentation and report to the physician promptly regarding any abnormality.According to a Transfer Summary written by Licensed Vocational Nurse 1 (LVN 1) dated 7/12/12, at 9:10 a.m., a therapist paged LVN 1 to report to the Rehab Gym (located on the second floor) because the resident did not look or feel good. Upon assessment with Registered Nurse (RN) Supervisor 1, the resident was responsive but was noted with shortness of breath and the oxygen saturation was 77% at room air. The normal oxygen saturation level is greater than 95 percent (%). Levels less than 95% indicate impaired cardiopulmonary function or abnormal gas exchange (Lippincott Williams & Wilkins 2009 Diagnostic Tests Made Incredibly Easy! - 2nd ed. page 419). The Transfer Summary also indicated the resident was immediately provided with oxygen at 15 L/min through a non-rebreathing mask (allows for the delivery of higher concentrations of oxygen). The vital signs were checked, the blood pressure was 128/72 millimeters of mercury (mmHg), the heart rate was 81 beats per minute, and the respiratory rate was 16 breaths per minute. The resident complained of pain of 10/10 (in a pain scale from zero to 10, zero indicating no pain and 10 the worst pain possible), but was not able to state where the pain was located. At 9:20 a.m., a certified nursing assistant, CNA 1, was called to assist transporting the resident to the room (on the third floor) for further assessment. At 9:25 a.m., the resident was returned to bed, her blood sugar level was checked and was 263 milligrams per deciliters (mg/dl), and six units of insulin (medication to lower the blood sugar level) was given. The resident was verbally responsive but her eyes were closed. The resident then became unresponsive, the blood pressure and oxygen saturation could not be reassessed because a reading could not be obtained after three attempts. LVN 1 informed RN Supervisor 1 to call 911 and cardiopulmonary resuscitation (CPR) was initiated. After the initial assessment (at 9:10 a.m.) of the resident's vital signs and oxygen saturation, there were no further measurements of the resident's vital signs to determine worsening or improvement of the resident's condition and the oxygen saturation level was not checked to determine if the resident was responding to the oxygen administered. Fifteen minutes later at 9:25 a.m., when the resident was back in her room, attempts to take the blood pressure and oxygen saturation failed.The nursing notes did not indicate time of arrival of the paramedics and time of transfer of the resident to the ER. However, according to the facility's investigation, the ambulance arrived at the facility at 9:40 a.m. and departed with the resident at 9:58 a.m.According to the Emergency Treatment Record from the acute hospital, the paramedics arrived at the facility and evaluated the resident who was noted to have a pulse at that time. The resident then went into PEA (pulseless electrical activity, a clinical condition characterized by unresponsiveness and lack of palpable pulse in the presence of organized cardiac electrical activity) and was intubated by the paramedic team. The resident arrived to the emergency department at 10:17 a.m., in full cardiac arrest and was pronounced dead at 10:43 a.m. The diagnoses were cardiac arrest and myocardial infarction. On 7/31/12 at 11:20 a.m., during an interview, LVN 1 stated she was working on the third floor, where the resident resided, when she was called to the Rehab Gym on the second floor. LVN 1 stated she found the resident sitting on a wheelchair outside the Rehab Gym having hard time breathing. LVN 1 stated the vital signs were already taken by another nurse when she saw the resident. LVN 1 stated she returned to the third floor to get CNA 1 to bring the resident back to her room while RN Supervisor 1 stayed with the resident on the second floor. LVN 1 stated when she returned to the third floor with CNA 1, the resident was already on 15 L/min of oxygen via non-rebreathing mask. When the resident was already in her bed, her condition changed (became unresponsive) and they could no longer obtain her vital signs and she informed RN Supervisor 1 the resident needed to go to the hospital.On 7/31/12 at 11:35 a.m., during an interview, RN Supervisor 1 stated Resident 1's vital signs were already taken when she saw the resident and she did not remember who initiated the administration of the oxygen. RN Supervisor 1 stated that during the transport from the second to the third floor, the resident was responding to name and questions. According to RN Supervisor 1, they took the resident back to her room for further assessment. She noticed the resident's hands were cold so she instructed LVN 1 to get her blood sugar level. RN Supervisor 1 stated the resident was still able to talk but suddenly stopped talking. When asked the reason why the physician was not notified, RN Supervisor 1 stated they were monitoring the resident closely and she wanted to perform a more complete assessment before calling the physician. However, RN Supervisor 1 could not explain the accuracy of the monitoring without vital signs values and without oxygen saturation levels. At 12 p.m., during an interview, the director of nursing (DON) stated an oxygen saturation of 77% was already alarming; however, the resident still had normal vital signs. The DON explained when a resident had a change of condition; staff normally places a pulse oximeter (a device placed on the tip of one of the fingers to measure the amount of oxygen in the blood and the pulse rate) for continuous monitoring of the oxygen saturation and the pulse rate. The DON also stated the oxygen saturation and vital signs should have been reassessed and the physician should have been notified of the resident's change of condition following the assessment.On 8/8/12 at 1:20 p.m., during a telephone interview, the resident's attending physician stated it was not necessary to call paramedics for low oxygen saturation but first the nurses should administer oxygen and check if the oxygen saturation improved. The physician also stated if he was notified he would give further instructions according to the resident's status. According to the facility's policy and procedure titled, "Physician notification of Change in Resident Condition," revised on 11/2005, the emergency notification will be made immediately and the licensed nurse will document the assessment and information given to the physician in the medical record. The facility's procedures also indicated the licensed nurse will be responsible for making all notifications of changes to the physician, the resident, and the resident representative. Examples of changes may include, but not limited to: changes in vital signs and abnormal finding, respiratory or cardiovascular changes and neurological changes - including mental status changes.The facility failed to provide Resident 1 with the necessary care in accordance with the assessment, plan of care, and facility's policy and procedure by nursing staff failing to: 1. Monitor the vital signs and oxygen saturation level after the resident was identified with a change of condition manifested by shortness of breath and low oxygen saturation and after oxygen was administered. 2. Contact the attending physician for further instructions regarding the care of the resident as stated in the plan of care and the facility?s policy and procedure. On 7/12/12, at 9:10 a.m., during a physical therapy session, Resident 1 became short of breath and had an oxygen saturation of 77% at room air. After the resident's sudden change of condition, initial assessment and intervention, the resident?s vital signs and oxygen saturation were not further monitored for 15 minutes to evaluate the resident's response to the oxygen intervention and the resident's attending physician was not contacted for further instructions. As a result, the resident was evaluated at the emergency room (ER) at 10:17 a.m., one hour and seven minutes after the change of condition was assessed. The resident arrived to the ER in full cardiac arrest and was pronounced dead at 10:43 a.m. The above violation had the direct or immediate relationship to the health, safety, or security of Resident 1. |
| 970000021 |
THE REHABILITATION CENTER ON LA BREA |
940009741 |
B |
12-Feb-13 |
3ONJ11 |
10700 |
F - 309 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. On 10/11/12 at 7:30 a.m., an unannounced visit was made to the facility to conduct a recertification survey.Based on observation, interview, and record review, the facility failed to provide Residents 8, 17 and 19, who received oral diet, with the necessary diabetic care in accordance with the assessment, plan of care, physician?s orders, and facility's policy and procedure by Licensed Vocational Nurse 1 (LVN 1) failing to: 1. Ensure blood sugar level monitoring before meals. 2. Ensure administration of insulin (injection used to control blood sugar) dosage based on the blood sugar level (sliding scale). On 10/11/12, during the midday medication pass, LVN 1 did not check the residents? blood sugar level and did not administer the insulin dose based on the abnormal results before lunch as ordered but until after lunch starting at 1:25 p.m., resulting in hyperglycemia (high blood sugar which may be mild or severe, symptoms can vary and may include extreme thirst, frequent urination, fatigue and blurred vision) and placing the residents at risk of hypoglycemia (low blood sugar with symptoms such as nervousness, shakiness, increased sweating and confusion).On 10/11/12, at 1:20 p.m., during an interview, LVN 1 stated she had not done the blood sugar checks ordered before the lunch meal. At 2:45 p.m., during another interview, LVN 1 stated she started at 1:25 p.m. checking the residents' blood sugar levels.During the course of the interview, the medication administration record (MAR) binder was reviewed with LVN 1. The residents with their corresponding blood sugar results taken starting at 1:25 p.m., were as follows: Resident 8's blood sugar (BS) was 400 mg/dL and 10 units of Insulin Lispro were administered, Resident 17's BS was 215 mg/dL and three units of Novolin Insulin were administered, and Resident 19's BS was 290 mg/dL and six units of Regular Insulin were administered. According to the American Diabetes Association website; http://www.diabetes.org/living-with-diabetes/parents-and-kids/planet-d/new-to-diabetes/insulin/; Rapid-acting insulin like Lispro (Humalog?), aspart (NovoLog?), or glulisine (Apidra?), is the fastest working of all insulins. Once you inject it, it starts to work (onsets) in about 5 minutes and works hardest (peaks) about an hour after injection. These insulin last (have a duration of) about 4 to 5 hours. It is taken right before meals. Rapid-acting insulin looks clear in the bottle. Short-acting insulin like "Regular" insulin is sometimes used around mealtime. It takes longer to work than rapid-acting insulin does. It's taken about 30-45 minutes before you plan to eat and it peaks about three to four hours later. It can keep working for as long as 6 hours after injection. It also looks clear in the bottle.At 3 p.m. during an interview, LVN 1 stated her regular assignment was to pass medications for residents assigned to Medication Cart # 2 in Nursing Station B. LVN 1 stated she spoke to the director of nursing (DON) the week prior about her heavy workload. When asked about the importance of prompt administration of rapid-acting insulin, LVN 1 did not answer.At 4 p.m., during an interview, the DON acknowledged LVN 1 informed him last week that her workload was heavy and the nurse consultant made a verbal recommendation to divide the residents more evenly between the two medication carts.A review of LVN 1's assignment indicated she had 35 residents under her care. 16 of the 35 residents were diabetic and required blood sugar checks by finger stick and insulin administration per sliding scale. Six of the 16 diabetic residents had gastrostomy tube (GT ? a tube surgically inserted in the stomach through the abdominal wall for nutrition and medication administration) feedings and ten residents received oral diets.According to the facility's meal time schedule for Nursing Station B, lunch was served at 12:15 p.m. A review of Resident 8's clinical record indicated the resident was admitted to the facility on 10/14/09 and readmitted on 9/8/12 with diagnoses that included diabetes mellitus, end stage renal disease, and renal dialysis status. According to the quarterly Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 9/1/12, the resident was alert and able to make his needs known, did not walk, needed supervision when eating and required extensive assistance with dressing, personal hygiene and transfers. A physician's order dated 9/8/12, indicated finger stick blood sugar (FSBS) before meals and at bedtime with Insulin Lispro SQ injection per sliding scale for the following blood sugar levels: 0 - 140 mg/dL= no insulin coverage 150 -199 mg/dL = two units of insulin 200 -249 mg/dL = four units of insulin 250 -299 mg/dL = six units of insulin 300 -349 mg/dL = eight units of insulin 350 -400 mg/dL = 10 units of insulin BS over 400 mg/dL = 12 units of insulin and call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m.A care plan dated 3/13/12, indicated the resident has labile (unstable) blood sugars related to diabetes mellitus. The approaches included to obtain the resident's finger stick blood sugars as ordered and FSBS three times a day (TID) before meals with Insulin Lispro per sliding scale.A review of Resident 17's clinical record indicated the resident was admitted to the facility on 9/13/12, with diagnoses that included diabetes mellitus. The admission MDS assessment dated 9/20/12, disclosed the resident was able to make his needs known, was able to understand others, did not walk, and required extensive assistance with activities of daily living (ADLs). A physician's order dated 9/15/12, indicated FSBS every six hours with Novolin Insulin SQ injection per sliding scale for the following blood sugar levels: 111-150 mg/dL = one unit of insulin 151-200 mg/dL = two units of insulin 201-249 mg/dL = three units of insulin 250-299 mg/dL = four units of insulin 300-349 mg/dL = five units of insulin 350-399 mg/dL = six units of insulin BS over 400 mg/dL = seven units of insulin and call the physician. According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 12 a.m., 6 a.m., 12 noon, and 6 p.m. The care plan dated 9/14/12, developed for the resident's risk for hypo/hyperglycemia related to diabetes mellitus, had a goal for the resident not to have signs and symptoms of hypo/hyperglycemia daily for 90 days. The approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, and blood sugar check(s) as ordered before meals and every bedtime with Novolin R Insulin SQ injection per sliding scale. A review of Resident 19's clinical record indicated the resident was admitted to the facility on 5/24/11, and readmitted on 10/9/12, with diagnoses that included diabetes mellitus. The quarterly MDS assessment dated 9/1/12, disclosed the resident was non-verbal or unable to make her needs known, did not walk, and required extensive to total assistance in ADLs. A physician's order dated 10/9/12, indicated FSBS before meals and at bedtime with Novolin R Insulin SQ injection per sliding scale for the following blood sugar levels: 150 -200 mg/dL = two units of insulin 201 -250 mg/dL = four units of insulin 251 -300 mg/dL = six units of insulin 301 -350 mg/dL = eight units of insulin 351 -400 mg/dL = 10 units of insulin BS over 400 mg/dL = 12 units of insulin and call the physician. According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m. A care plan dated 3/1/12, developed for the resident's risk of hypo/hyperglycemia related to diabetes and one of the goals was to have no signs and symptoms of hypo/hyperglycemia daily for 90 days. The approaches included to obtain resident ' s finger stick blood sugars as ordered and accucheck(blood sugar check) before meals and at bedtime with sliding scale. A review of the summary of the facility's job description for the Licensed Vocational Nurse indicated duties and responsibilities which included rendering professional nursing care to residents, performing nursing techniques for the comfort and well-being of the resident, maintaining resident's medical records on nursing observations, assisting physician during treatment and examination of the resident, and administering prescribed medications.According to the facility's undated policy and procedure titled "Guidelines for Medication Administration," routinely ordered medications will be administered at the times specified in the Standard Times for Medication Doses described in Appendix M. Appendix M specified the time for AC (before meals) as 6:30 a.m., 11:30 a.m., and 4:30 p.m. On 10/15/12, at 10:30 a.m., during an interview, the facility's Pharmacist Consultant stated he was not aware of licensed staff's delaying administration of medications. On 10/18/12, at 4 p.m. during an interview with registered nurse (RN) Supervisor 1, she stated she was unaware of the morning medication pass not being completed in a timely manner. RN supervisor1 indicated she had not observed LVN 1 taking the whole shift to pass medications, nor could she recall any of the residents complaining that their medications were late. She also stated she did not recall a conversation with LVN 1 regarding her workload. The facility failed to provide Residents 8, 17 and 19, who received oral diets, with the necessary diabetic care in accordance with the assessment, plan of care, physician?s orders, and facility's policy and procedure by LVN 1 failing to: 1. Ensure blood sugar level monitoring before meals. 2. Ensure administration of insulin (injection used to control blood sugar) dosage based on the blood sugar level (sliding scale). On 10/11/12, during the midday medication pass, LVN 1 did not check the residents? blood sugar level and did not administer the insulin dose based on the abnormal results before lunch as ordered but until after lunch starting at 1:25 p.m., resulting in hyperglycemia and placing the residents at risk of hypoglycemia. The above violation had the direct or immediate relationship to the health, safety, or security of Residents 8, 17 and 19. |
| 970000021 |
THE REHABILITATION CENTER ON LA BREA |
940009742 |
B |
12-Feb-13 |
3ONJ11 |
16179 |
F - 309 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. On 10/11/12 at 7:30 a.m., an unannounced visit was made to the facility to conduct a recertification survey.Based on observation, interview and record review, the facility failed to provide Residents 4, 12, 20, 27, 28, 32 and 33, who received oral diet, with the necessary diabetic care in accordance with the assessment, plan of care, physician?s orders, and facility's policy and procedure by Licensed Vocational Nurse 1 (LVN 1) failing to: 1. Ensure blood sugar level monitoring before meals. 2. Ensure administration of insulin (insulin used to control blood sugar) dosage based on the blood sugar level (sliding scale). On 10/11/12, during the midday medication pass, LVN 1 did not check the residents? blood sugar level ordered before lunch at 11:30 a.m., but until after lunch starting at 1:25 p.m., placing the residents at risk of serious hypoglycemia (low blood sugar with symptoms such as nervousness, shakiness, increased sweating and confusion) or hyperglycemia (high blood sugar which may be mild or severe, symptoms can vary and may include extreme thirst, frequent urination, fatigue and blurred vision).On 10/11/12, at 1:20 p.m., during an interview, LVN 1 stated she had not done the blood sugar checks ordered before the lunch meal. At 2:45 p.m., during another interview, LVN 1 stated she started at 1:25 p.m. checking the residents' blood sugar levels. During the course of the interview, the Medication Administration Record (MAR) binder was reviewed with LVN 1. The residents with their corresponding blood sugar results taken starting at 1:25 p.m. were as follows: Resident 4's blood sugar (BS) was 126 milligrams per deciliters (mg/dL) and no insulin coverage was given, Resident 12's BS was 95 mg/dL and no insulin coverage was given, Resident 20's BS was 125 mg/dL and no insulin coverage was given, Resident 27's BS was 125 mg/dL and no insulin coverage was given, Resident 28's BS was 93 mg/dL and no insulin coverage was given, Resident 32's BS was 134 mg/dL and no insulin coverage was given, and Resident 33's BS was 112 mg/dL and no insulin coverage was given. According to the American Diabetes Association website; http://www.diabetes.org/living-with-diabetes/parents-and-kids/planet-d/new-to-diabetes/insulin/; Rapid-acting insulin like Lispro (Humalog?), aspart (NovoLog?), or glulisine (Apidra?), is the fastest working of all insulins. Once you inject it, it starts to work (onsets) in about 5 minutes and works hardest (peaks) about an hour after injection. These insulin last (have a duration of) about 4 to 5 hours. It is taken right before meals. Rapid-acting insulin looks clear in the bottle. Short-acting insulin like "Regular" insulin is sometimes used around mealtime. It takes longer to work than rapid-acting insulin does. It's taken about 30-45 minutes before you plan to eat and it peaks about three to four hours later. It can keep working for as long as 6 hours after injection. It also looks clear in the bottle. At 3 p.m. during an interview, LVN 1 stated her regular assignment was to pass medications for residents assigned to Medication Cart # 2 in Nursing Station B. LVN 1 stated she spoke to the director of nursing (DON) the week prior about her heavy workload. When asked about the importance of prompt administration of rapid-acting insulin, LVN 1 did not answer.A review of LVN 1's assignment indicated she had 35 residents under her care. 16 of the 35 residents were diabetic and required blood sugar checks by finger stick and insulin administration per sliding scale. Six of the 16 diabetic residents had gastrostomy tube (GT ? a tube surgically inserted in the stomach through the abdominal wall for nutrition and medication administration) feedings and 10 residents received oral diets.According to the facility's meal time schedule for Nursing Station B, lunch was served at 12:15 p.m. A review of Resident 4's clinical record indicated the resident was admitted to the facility on 10/2/12 with diagnoses that included diabetes mellitus, hypertension (high blood pressure), and end stage renal disease. According to the admission Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 10/9/12, the resident was able to make his needs known and understand others, and required extensive assistance with activities of daily living (ADLs). A physician's order dated 10/2/12, indicated finger stick blood sugar (FSBS) four times a day (QID) before meals and at bedtime with Regular Insulin subcutaneous (SQ ? under the skin) injection per sliding scale as follows: 150 -200 mg/dL = two units of insulin 201 -250 mg/dL = four units of insulin 251 -300 mg/dL = six units of insulin 301 -350 mg/dL = eight units of insulin 351 -400 mg/dL = 10 units of insulin BS over 400 mg/dL = 12 units of insulin and call the physician. According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m.According to the care plan, dated 10/3/12, the resident was at risk for hypo/hyperglycemia related to diabetes and one of the goals was to have no signs and symptoms of hypo/hyperglycemia daily for 90 days. The approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, and blood sugar check(s) as ordered, and administer Regular Insulin per sliding scale before meals and at bedtime. A review of Resident 12's clinical record indicated the resident was admitted to the facility on 4/24/12, and readmitted on 6/14/12, with diagnoses that included diabetes mellitus and hypertension. According to the MDS assessment dated 10/9/12, the resident was able to make her needs known and able to understand others usually, and required extensive to total assistance with ADLs. A physician's order dated 6/14/12, indicated FSBS before meals and at bedtime with Humalog Insulin SQ injection per sliding scale as follows: BS less than 110 mg/dL = no coverage 111-126 mg/dL = two units of insulin 127-150 mg/dL = three units of insulin 151-200 mg/dL = four units of insulin 201-250 mg/dL = six units of insulin 251-300 mg/dL = eight units of insulin 301-350 mg/dL = 10 units of insulin 351-400 mg/dL = 12 units of insulin BS over 400 mg/dL = 14 units of insulin and call the physician. According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 8 p.m. A care plan dated 4/27/12, developed for hypo/hyperglycemia related to diabetes mellitus, the approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, and blood sugar check(s) as ordered. A review of Resident 20's clinical record indicated the resident was admitted to the facility on 3/16/12, and readmitted on 4/24/12, with diagnoses that included diabetes mellitus, hypertension (high blood pressure), GT, and dysphagia. According to the quarterly MDS assessment dated 8/21/12, the resident usually was able to make her needs known and understand others, received nutrition by mouth and by GT, and required limited to extensive assistance with ADLs. A physician?s order dated 6/12/12, indicated the feeding via GT 12 hours a day from 6 a.m. to 6 p.m. Another physician?s order dated 6/20/12, indicated oral mechanical no added salt diet. A physician?s order dated 9/14/12, indicated FSBS before meals three times a day (TID) with Regular Insulin SQ injection per sliding scale for the following blood sugar levels: 150 -200 mg/dL = two units of insulin 201 -250 mg/dL = four units of insulin 251 -300 mg/dL = six units of insulin 301 -350 mg/dL = eight units of insulin 351 -400 mg/dL = 10 units of insulin and call the physician If BS below 60 = give orange juice and call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., and 4:30 p.m. A care plan dated 5/22/12, developed for the resident's risk of hypo/hyperglycemia related to diabetes and the goal was to have no signs and symptoms of hypo/hyperglycemia daily for 90 days. The approaches included to obtain labs as ordered with abnormal results reported promptly to the physician.A review of Resident 27's clinical record indicated the resident was admitted to the facility on 9/28/12, with diagnoses that included diabetes mellitus, hypertension, and congestive heart failure (the heart cannot pump enough blood to the rest of the body). According to the admission MDS assessment dated 10/8/12, the resident was able to make his needs known, was able to understand others, and required extensive assistance with ADLs.A physician's order dated 9/28/12 indicated an order for FSBS before meals and at bedtime with Novolog Insulin SQ injection per sliding scale as follows: BS below 150 mg/dL = no coverage 150 -199 mg/dL = one unit of insulin 200 -249 mg/dL = two units of insulin 250 -299 mg/dL = three units of insulin 300 -349 mg/dL = four units of insulin 350 -400 mg/dL = five units of insulin BS over 400 mg/dL = call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m.A care plan dated 9/28/12, developed for the resident's risk for hypo/hyperglycemia related to diabetes had a goal for the resident not to have signs and symptoms of hypo/hyperglycemia daily for 90 days. The approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, and blood sugar check(s) as ordered before meals and at bedtime with Novolog Insulin SQ injection per sliding scale. A review of Resident 28's clinical record indicated the resident was admitted to the facility on 12/13/11 and re-admitted on 9/27/12 with diagnoses that included diabetes mellitus and hypertension. According to the admission MDS assessment dated 10/7/12, the resident was able to make his needs known, was able to understand others, did not walk, and required extensive assistance in ADLs.A physician's order dated 9/27/12 indicated FSBS QID before meals and at bedtime with Novolog Insulin SQ injection per sliding scale as follows: BS below 150 mg/dL = no coverage 150 -199 mg/dL = one unit of insulin 200 -249 mg/dL = three units of insulin 250 -299 mg/dL = five units of insulin 300 -349 mg/dL = seven units of insulin 350 -400 mg/dL = nine units of insulin BS over 400 mg/dL or below 45 mg/dL = call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m.According to the care plan dated 6/11/12, the resident was at risk for hypo/hyperglycemia related to diabetes and one of the goals was to have no signs and symptoms of hypo/hyperglycemia daily for 90 days. The approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, and blood sugar check(s) as ordered.A review of Resident 32's clinical record indicated the resident was admitted to the facility on 10/6/12 with diagnoses that included diabetes mellitus and hypertension. According to the admission MDS assessment dated 10/16/12, the resident was able to make his needs known and understand others, did not walk, and required extensive assistance in ADLs. A physician's order dated 10/6/12, indicated to do accucheck before meals and at bedtime, call the physician if BS was below 70 or over 300, and give orange juice if BS was below 70. Another order indicated to administer three units of Lispro Insulin SQ injection three times a day (TID) before meals and hold for BS over 150 mg/dL, and Lantus Insulin 10 units SQ daily at bedtime. According to the MAR the blood sugar monitoring and the insulin injection was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m.A review of Resident 33's clinical record indicated the resident was admitted to the facility on 9/22/12 with diagnoses that included diabetes mellitus, GT, dysphagia, and hypertension. According to the admission MDS assessment dated 10/2/12, the resident was able to make his needs known and understand others, did not walk, needed supervision when eating, and required extensive to total assistance with ADLs.A physician?s order dated 9/22/12, indicated reduced concentrated sweet diet. Another physician's order dated 9/22/12, indicated accucheck before meals and at bedtime with Regular Insulin per sliding scale as follows: BS below 70 = give orange juice and call the physician 0 -149 mg/dL = no coverage 150 -200 mg/dL = two units of insulin 201 -250 mg/dL = four units of insulin 251 -300 mg/dL = six units of insulin 301 -350 mg/dL = eight units of insulin 351 -400 mg/dL = 10 units of insulin BS over 400 mg/dL = 12 units of insulin and call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m.According to the care plan dated 10/8/12, the resident was at risk for hypo/hyperglycemia related to diabetes and one of the goals was to have no signs and symptoms of hypo/hyperglycemia daily for 90 days. The approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, blood sugar check before meals and at bedtime, call the physician for BS below 70 and over 300, and administer Lispro Insulin three units SQ injection TID before meals but hold for BS below 150 mg/dL. A review of the summary of the facility's job description for the Licensed Vocational Nurse indicated duties and responsibilities which included rendering professional nursing care to residents, performing nursing techniques for the comfort and well-being of the resident, maintaining resident's medical records on nursing observations, assisting physician during treatment and examination of the resident, and administering prescribed medications.According to the facility's undated policy and procedure titled "Guidelines for Medication Administration," routinely ordered medications will be administered at the times specified in the Standard Times for Medication Doses described in Appendix M. Appendix M specified the time for AC (before meals) as 6:30 a.m., 11:30 a.m., and 4:30 p.m. On 10/15/12, at 10:30 a.m., during an interview, the facility's Pharmacist Consultant stated he was not aware of licensed staff's delaying administration of medications. On 10/18/12, at 4 p.m. during an interview with registered nurse (RN) Supervisor 1, she stated she was unaware of the morning medication pass not being completed in a timely manner. The RN supervisor then indicated she had not observed LVN 1 taking the whole shift to pass medications, nor could she recall any of the residents complaining that their medications were late. She also stated she did not recall a conversation with LVN 1 regarding her workload. The facility failed to provide Residents 4, 12, 20, 27, 28, 32 and 33, who received oral diet, with the necessary diabetic care in accordance with the assessment, plan of care, physician?s orders, and facility's policy and procedure by LVN 1 failing to: 1. Ensure blood sugar level monitoring before meals. 2. Ensure administration of insulin dosage based on the blood sugar level. On 10/11/12, during the midday medication pass, LVN 1 did not check the residents? blood sugar level ordered before lunch at 11:30 a.m., but until after lunch starting at 1:25 p.m., placing the residents at risk of serious hypoglycemia or hyperglycemia.The above violation had the direct or immediate relationship to the health, safety, or security of Residents 4, 12, 20, 27, 28, 32 and 33. |
| 970000021 |
THE REHABILITATION CENTER ON LA BREA |
940009743 |
B |
12-Feb-13 |
3ONJ11 |
11415 |
F - 309 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. On 10/11/12 at 7:30 a.m., an unannounced visit was made to the facility to conduct a recertification survey.Based on observation, interview and record review, the facility failed to provide Residents 3, 29, 30, and 31, who received nutrition through a feeding tube, with the necessary diabetic care in accordance with the assessment, plan of care, physician?s orders, and facility's policy and procedure by Licensed Vocational Nurse 1 (LVN 1) failing to: 1. Ensure blood sugar level monitoring. 2. Ensure administration of insulin (insulin used to control blood sugar) dosage based on the blood sugar level (sliding scale). On 10/11/12, during the midday medication pass, LVN 1 did not check the residents? blood sugar level ordered at 11:30 a.m. or at 12 noon, instead started at 1:25 p.m., placing the residents at risk of serious hypoglycemia (low blood sugar with symptoms such as nervousness, shakiness, increased sweating and confusion) or hyperglycemia (high blood sugar which may be mild or severe, symptoms can vary and may include extreme thirst, frequent urination, fatigue and blurred vision).On 10/11/12, at 1:20 p.m., during an interview, LVN 1 stated she had not done the blood sugar checks ordered at11:30 a.m. or at 12 noon. At 2:45 p.m., during another interview, LVN 1 stated she started at 1:25 p.m. checking the residents' blood sugar levels. During the course of the interview, the Medication Administration Record (MAR) binder was reviewed with LVN 1. The residents with their corresponding blood sugar results taken starting at 1:25 p.m. were as follows: Resident 3's blood sugar (BS) was 120 milligrams per deciliters (mg/dL) and no insulin coverage was given, Resident 29's BS was 98 mg/dL and no insulin coverage was given, Resident 30's BS was 135 mg/dL and no insulin coverage was given, and Resident 31's BS was 116 mg/dL and no insulin coverage was given. At 3 p.m. during an interview, LVN 1 stated her regular assignment was to pass medications for residents assigned to Medication Cart # 2 in Nursing Station B. LVN 1 stated she spoke to the director of nursing (DON) the week prior about her heavy workload.At 4 p.m., during an interview, the DON acknowledged LVN 1 informed him last week that her workload was heavy and the nurse consultant made a verbal recommendation to divide the residents more evenly between the two medication carts.A review of LVN 1's assignment indicated she had 35 residents under her care. 16 of the 35 residents were diabetic and required blood sugar checks by finger stick and insulin administration per sliding scale. Six of the 16 diabetic residents had gastrostomy tube (GT ? a tube surgically inserted in the stomach through the abdominal wall for nutrition and medication administration) feedings and ten residents received oral diets.According to the facility's meal time schedule for Nursing Station B, lunch was served at 12:15 p.m. A review of Resident 3's clinical record indicated the resident was admitted to the facility on 5/26/12 and re-admitted on 8/25/12 with diagnoses that included diabetes mellitus, GT and dysphagia (difficulty swallowing). The quarterly Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 9/1/12, indicated the resident was severely impaired in cognitive skills for daily decision-making, did not walk, received nutrition via GT, and needed extensive to total assistance with activities of daily living (ADLs). A physician's order dated 8/25/12, indicated finger stick blood sugar (FSBS) four times a day (QID) with Humalog Insulin subcutaneous (SQ ? under the skin) injection per sliding scale for the following blood sugar levels: 71-130 mg/dL = no insulin coverage 131-150 mg/dL = one unit of insulin 151-200 mg/dL = two units of insulin 201-250 mg/dL = four units of insulin 251-300 mg/dL = six units of insulin 301-350 mg/dL = eight units of insulin 351-400 mg/dL = 10 units of insulin BS over 400 mg/dL = 12 units of insulin and call the physician. According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9 p.m.According to the care plan, dated 5/27/12, the resident was at risk for hypo/hyperglycemia episodes related to diabetes mellitus and the goal was to minimize further episodes of hypo/hyperglycemia daily for 90 days. One of the approaches indicated to administer Humalog Insulin with accucheck (blood sugar check) before meals and at bedtime. A review of Resident 29's clinical record indicated the resident was admitted to the facility on 5/6/12 and re-admitted on 9/26/12 with diagnoses that included diabetes mellitus, GT and seizure disorder. According to the significant change in status MDS assessment dated 9/13/12, the resident sometimes was able to make his needs known and understand others, did not walk, and required extensive to total assistance in ADLs.A physician's order dated 9/26/12, indicated FSBS every six hours with Regular Insulin SQ injection per sliding scale as follows: BS below 70 mg/dL = give orange juice per GT 150 -199 mg/dL = two units of insulin 200 -249 mg/dL = four units of insulin 250 -300 mg/dL = six units of insulin 301 -350 mg/dL = eight units of insulin 351 -400 mg/dL = 10 units of insulin BS over 400 mg/dL and below 70 mg/dL = call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 12 a.m., 6 a.m., 12 noon, and 6 p.m. According to the care plan, dated 5/7/12, the resident was at risk for hypo/hyperglycemia related to diabetes and one of the goals was to have no signs and symptoms of hypo/hyperglycemia daily for 90 days. The approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, and blood sugar check(s) as ordered.A review of Resident 30's clinical record indicated the resident was admitted to the facility on 8/16/07, and readmitted on 9/21/12, with diagnoses that included diabetes mellitus, GT and hypertension. According to the quarterly MDS assessment dated 8/27/12, the resident usually was able to make her needs known and understand others, had modified independence for cognitive skills for daily decision making, did not walk, and was totally dependent on staff in ADLs. A physician's order dated 9/21/12 indicated FSBS every six hours with Novolog Insulin SQ injection per sliding scale as follows: BS below 70 mg/dL = give orange juice per GT and call the physician 150 -200 mg/dL = two units of insulin 201 -250 mg/dL = four units of insulin 251 -300 mg/dL = six units of insulin 301 -350 mg/dL = eight units of insulin 351 -400 mg/dL = 10 units of insulin BS over 400 mg/dL = 12 units of insulin and call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 12 a.m., 6 a.m., 12 noon, and 6 p.m. A care plan dated 3/5/12, developed for the resident's risk of hypo/hyperglycemia related to diabetes had a goal for the resident to have blood sugar level below 120 mg/dL and not to require additional insulin for 90 days. The approaches included to obtain resident's finger stick blood sugars as ordered. A review of Resident 31's clinical record indicated the resident was admitted to the facility on 6/25/11, and readmitted on 9/21/12, with diagnoses that included diabetes mellitus, GT, and end stage renal disease. According to quarterly MDS assessment dated 8/24/12, the resident sometimes was able to make his needs known and understand others, did not walk, and required extensive to total assistance in ADLs. A physician's order dated 9/21/12, indicated FSBS QID with Lispro Insulin SQ injection per sliding scale as follows: BS below 70 mg/dL = give orange juice per GT and call the physician 150 -200 mg/dL = two units of insulin 201 -250 mg/dL = four units of insulin 251 -300 mg/dL = six units of insulin 301 -350 mg/dL = eight units of insulin 351 -400 mg/dL = 10 units of insulin BS over 400 mg/dL = call the physician According to the MAR, the blood sugar monitoring with insulin per sliding scale was scheduled at 12 a.m., 6 a.m., 12 noon, and 6 p.m. According to the care plan dated 3/7/12, the resident was at risk for hypo/hyperglycemia related to diabetes and one of the goals was to have no signs and symptoms of hypo/hyperglycemia daily for 90 days. The approaches included to administer the medication as ordered, monitor the effect of the medication and report to the physician if indicated, and blood sugar check(s) as ordered.A review of the summary of the facility's job description for the Licensed Vocational Nurse indicated duties and responsibilities which included rendering professional nursing care to residents, performing nursing techniques for the comfort and well-being of the resident, maintaining resident's medical records on nursing observations, assisting physician during treatment and examination of the resident, and administering prescribed medications.According to the facility's undated policy and procedure titled "Guidelines for Medication Administration," routinely ordered medications will be administered at the times specified in the Standard Times for Medication Doses described in Appendix M. Appendix M specified the time for AC (before meals) as 6:30 a.m., 11:30 a.m., and 4:30 p.m. A review of the Consultant Pharmacist's Recommendation to the Inter-Disciplinary Team (IDT), dated 10/15/12, indicated a recommendation to either discontinue if feasible the vitamins and supplements for 24 residents in Nursing Station B or if not feasible, to consider changing the administration times to reduce the AM (morning) medication pass pill burden. On 10/15/12, at 10:30 a.m., during an interview, the facility's Pharmacist Consultant stated he was not aware of licensed staff's delaying administration of medications. On 10/18/12, at 4 p.m. during an interview with RN Supervisor 1, she stated she was unaware of the morning medication pass not being completed in a timely manner. The RN supervisor then indicated she had not observed LVN 1 taking the whole shift to pass medications, nor could she recall any of the residents complaining that their medications were late. She also stated she did not recall a conversation with LVN 1 regarding her workload. The facility failed to provide Residents 3, 29, 30, and 31, who received nutrition through a feeding tube, with the necessary diabetic care in accordance with the assessment, plan of care, physician?s orders, and facility's policy and procedure by LVN 1 failing to: 1. Ensure blood sugar level monitoring. 2. Ensure administration of insulin dosage based on the blood sugar level. On 10/11/12, during the midday medication pass, LVN 1 did not check the residents? blood sugar level ordered at 11:30 a.m. or 12 noon, but starting at 1:25 p.m., placing the residents at risk of serious hypoglycemic or hyperglycemic reaction.The above violation had the direct or immediate relationship to the health, safety, or security of Residents 3, 29, 30, and 31. |
| 970000021 |
THE REHABILITATION CENTER ON LA BREA |
940009744 |
B |
12-Feb-13 |
3ONJ11 |
11171 |
F - 309 483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. On 10/11/12 at 7:30 a.m., an unannounced visit was made to the facility to conduct a recertification survey.Based on observation, interview and record review, the facility failed to provide Residents 8, 15, 18, 20, and 26, with the necessary care in accordance with the assessment, plan of care, physician?s orders, and facility's policy and procedure by Licensed Vocational Nurse 1 (LVN 1) failing to: Ensure medications were administered as prescribed. On 10/11/12, by 12:30 p.m., LVN 1 had not administered the residents? morning medications, placing the residents at risk of ineffective medication therapy, adverse reactions, medication interactions, complications such as hypoglycemia (low blood sugar), hypertension (high blood pressure), and elevated blood levels of ammonia and phosphorus (regulated by the kidney). On 10/11/12, at 12:30 p.m., a review of the Medication Administration Record (MAR) disclosed no documentation of the medication administration scheduled for the morning for Residents 8, 15, 18, 20 and 26. At the time of the MAR review, LVN 1 stated she had not yet given their medications and explained she usually began the medication pass with the residents who received medications via gastrostomy tube (GT ? a tube surgically inserted in the stomach through the abdominal wall for nutrition and medication administration), and residents who were requesting pain medications, then she would administer medications for the other residents afterwards, as they, "Did not require a lot of attention.? A review of Resident 8's clinical record indicated the resident was admitted to the facility on 10/14/09, and readmitted on 9/8/12, with diagnoses that included diabetes mellitus (usually a lifelong disease in which there are high levels of sugar in the blood), end stage renal disease on hemodialysis (removal of toxic substances or metabolic wastes from the bloodstream using a filtering machine), and hepatic encephalopathy (worsening of brain function that occurs when the liver is no longer able to remove toxic substances in the blood including ammonia).According to the quarterly Minimum Data Set (MDS ? standardized assessment and care planning tool) dated 9/1/12, the resident was alert and able to make his needs known, did not walk, needed supervision when eating and required extensive assistance with dressing, personal hygiene and transfers. A physician?s order dated 9/8/12, indicated to give Renvela (to reduce blood levels of phosphorus in people with chronic kidney disease who are on dialysis) 2400 milligrams (mg), three tablets orally three times daily with meals scheduled at 7:15 a.m., 12:15 p.m., and 5:15 p.m. The order also indicated not to give other medications one hour before or three hours after the administration of Renvela (Renvela attaches to other medications affecting their absorption). Another physician?s order dated 9/8/12, indicated Methadone (narcotic pain reliever) 20 mg orally daily for pain management, which was scheduled at 9 a.m. A physician?s order dated 9/16/12, indicated Lactulose 20 grams (for hepatic encephalopathy - to reduce blood levels of ammonia) orally four times a day, scheduled at 9 a.m., 1 p.m., 5 p.m., and 9 p.m. A care plan dated 3/13/12, developed for the resident?s risk for complications related to dialysis, included in the approaches to give medications as ordered. On 10/11/12, by 12:30 p.m., the resident had not received the 7:15 a.m. dose of Renvela, the 9 a.m. dose of Methadone and the 9 a.m. dose of Lactulose. The second dose of Renvela was due at 12:15 p.m. with the lunch meal the resident had already eaten and the second dose of Lactulose was due at 1 p.m.A delay in administration of Lactulose and Renvela and the administration of two doses of the medications too close together or simultaneously had the potential to result in drug interactions, adverse reactions, and ineffective drug therapy (Renvela bind to other medications affecting their absorption). A delay in administration of Methadone could result in ineffective pain management and marked sedation due to cumulative effect (more pronounce effect).A review of Resident 15's clinical record disclosed an admission to the facility on 9/28/12, with diagnoses including chronic kidney disease, dementia (loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior), and diabetes. The MDS assessment dated 10/8/12, indicated the resident was usually able to be understood and to understand others, and required extensive staff assistance with all of his activities of daily living (ADLs). The physician?s order on admission included Metformin (anti-diabetic) 1000 mg orally twice a day with meals.A care plan developed on 9/28/12, for the resident?s risk of hyperglycemia (high blood sugar) or hypoglycemia related to diabetes, included in the approaches to give medications as ordered.According to the MAR, the morning dose of Metformin was scheduled to be given at 7:15 a.m., with breakfast; however, by 12:30 p.m., it was not given. A delayed Metformin dose could result in hyperglycemia. A review of Resident 18's clinical record indicated the resident was admitted to the facility on 1/30/12, with diagnoses that included dementia and diabetes. The MDS assessment dated 8/4/12, revealed the resident was moderately cognitively impaired (decisions poor; cueing required), was incontinent of bowel and bladder, and required extensive staff assistance with all ADLs.A physician?s order dated 1/20/12, indicated to give Amaryl (anti-diabetic) 2 mg by mouth daily with breakfast.A care plan developed since admission, for the resident?s risk of hyperglycemia or hypoglycemia related to diabetes, included in the approaches to give medications as ordered.According to the MAR, the morning dose was scheduled to be given at 7:15 a.m., with breakfast; however, by 12:30 p.m. it was not given.A delayed Amaryl dose could increase the possibility of the resident developing hyperglycemia. A review of Resident 20's clinical record disclosed the resident was readmitted to the facility on 4/24/12 with diagnoses that included acute respiratory failure, hypertension, and diabetes. The MDS assessment dated 8/4/12, indicated the resident was severely cognitively impaired and required extensive staff assistance with all ADLs. A physician?s order dated 7/16/12, indicated Metoprolol 50 mg orally twice a day with meals for hypertension and to hold the medication if the systolic blood pressure (the pressure exerted on the bloodstream by the heart when it contracts) was below 110 millimeters of Mercury (mmHg) . Another order dated 8/5/12, indicated to give Metformin 500 mg by mouth daily for diabetes. A plan of care dated 3/17/12, developed for the resident?s risk of hypoglycemia and hyperglycemia related to diabetes, included in the approaches to give medications as ordered.According to the MAR, the morning dose of Metoprolol was scheduled to be given at 7:15 a.m. and the Metformin was scheduled at 9 a.m. However, by 12:30 p.m. neither medication was given. A delay in the administration of Metoprolol can result in elevated blood pressure and a delayed dose of Metformin could result in hyperglycemia. A review of Resident 26's clinical record revealed the resident was admitted to the facility on 10/14/08, with diagnoses that included hypertension and dementia. The MDS assessment dated 8/3/12, indicated the resident's cognitive status was severely impaired and the resident required limited staff assistance with her ADLs. A physician?s order dated 10/9/12, indicated Gentamicin (antibiotic to treat infection) eye drops, one drop to both eyes twice a day for five days. According to the MAR, the morning dose of Gentamicin was scheduled to be given at 9 a.m. However, by 12:30 a.m., Gentamicin was not given. A delayed administration of antibiotic could result in ineffective drug therapy and delayed healing of the eye infection. A review of the summary of the facility's job description for the Licensed Vocational Nurse indicated duties and responsibilities which included rendering professional nursing care to residents, performing nursing techniques for the comfort and well-being of the resident, maintaining resident's medical records on nursing observations, assisting physician during treatment and examination of the resident, and administering prescribed medications.According to the facility's undated policy and procedure titled "Guidelines for Medication Administration," All scheduled medications, except those specifically ordered AC (before meals) or PC (after meals) should be administered in the time frame one hour before or one hour after the scheduled time dose time:Daily at 9 a.m. Twice a day (BID), at 9 a.m. and 5 p.m. Three times a day (TID), at 9 a.m. 1 p.m. and 5 p.m. Four times a day (QID), at 9 a.m. 1 p.m. 5 p.m. and 9 p.m.At 3 p.m., during an interview, LVN 1 stated her regular assignment was to pass medications for residents assigned to Medication Cart # 2 in Nursing Station B. LVN 1 stated she spoke to the director of nursing (DON) the week prior about her heavy workload. A review of LVN 1's assignment indicated she had 35 residents under her care.At 4 p.m., during an interview, the DON acknowledged LVN 1 informed him last week that her workload was heavy and the nurse consultant made a verbal recommendation to divide the residents more evenly between the two medication carts.On 10/15/12 at 10:30 a.m., during an interview, the facility's Pharmacist Consultant stated he was not aware of licensed staff's delaying administration of medications. On 10/18/12 at 4 p.m., during an interview with registered nurse (RN) Supervisor 1, she stated she was unaware of the morning medication pass not being completed in a timely manner. She then indicated she had not observed LVN 1 taking the whole shift to pass medications, nor could she recall any of the residents complaining that their medications were late. She also stated she did not recall a conversation with LVN 1 regarding her workload. The facility failed to provide Residents 8, 15, 18, 20, and 26, with the necessary care in accordance with the assessment, plan of care, physician?s orders, and facility's policy and procedure by LVN 1 failing to: Ensure medications were administered as prescribed. On 10/11/12, by 12:30 p.m., LVN 1 had not administered the residents? morning medications, placing the residents at risk of ineffective medication therapy, adverse reactions, medication interactions, complications such as hypoglycemia, hypertension, and elevated blood levels of ammonia and phosphorus. The above violation had the direct or immediate relationship to the health, safety, or security of Residents 8, 15, 18, 20, and 26. |
| 970000021 |
THE REHABILITATION CENTER ON LA BREA |
940011713 |
A |
29-Sep-15 |
69GP11 |
8918 |
483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. On August 10, 2015, 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 provide Resident 1, who had a hard cast to the left lower extremity from the thigh to the beginning of the toes, with the necessary care and services by failing to ensure:1. The licensed nurses monitored the exposed toes of the left foot for signs and symptoms of infection (such as odor, presence of fluid or drainage and increased temperature of the area), for circulation on the toes, changes in size, color, and presence of pain on the left foot. 2. The physician's order regarding cast care was followed. 3. A care plan was developed for the care and use of a hard cast. 4. A policy and procedure was in place regarding cast care. As a result Resident 1 developed gangrene (dead tissue caused by an infection or lack of blood flow) of the left toes and a pressure sore Stage IV (deep ulcer with damage to the muscle and bone caused by pressure) to the dorsum (the upper surface) of the left foot.A review of the clinical record indicated Resident 1 was initially admitted on May 28, 2015, with diagnoses which included Alzheimer's disease (a progressive disease which destroys memory and other mental functions), pulmonary hypertension (increased blood pressure in the pulmonary circulations), and closed fracture (the broken bone does not break the skin) of the left lower leg. A review of the Minimum Data Set (MDS - a standardized assessment care and screening tool), dated June 4, 2015, indicated Resident 1 was severely impaired in cognitive skills for daily decision-making and required total assistance from staff for activities with daily living.A review of Resident 1's History and Physical Examination, dated May 29, 2015, documented by Physician 1, indicated the resident was admitted to the facility with a left tibia/fibula fracture (inner of the two bones of the leg, which extend from the knee to the ankle) and a splint/cast on the resident's left lower extremity. A splint is a strip of rigid material used for supporting and immobilizing a broken bone of a limb that can easily be removed, while a cast is a shell made from plaster encasing a limb to stabilize and hold broken bones in place until healing. A cast removal requires special equipment. A review of the physician's order, dated May 29, 2015, indicated to monitor Resident 1's left lower extremity splint for any changes. According to the recapitulated physician's orders, dated June 2015, Resident 1 had an appointment with the orthopedist physician, Physician 2 (physician who treats bone and muscle illnesses and conditions), on June 3, 2015, who ordered on June 4, 2015, cast care for Resident 1. A review of the clinical record indicated there was no plan of care developed or updated regarding cast care (no longer a splint) to be provided to Resident 1.A review of Resident 1's physician's progress notes, dated June 22 and 29, 2015, documented by the nurse practitioner, indicated the resident had a cast, but there was no documentation of an assessment regarding the skin condition of the left toes. On June 29, 2015, the nurse practitioner documentation did not indicate the presence of any adverse changes to the left foot. The nursing notes, dated from May 29, 2015 through June 29, 2015, had no documented evidence the licensed nurse assessed the skin condition of Resident 1's left toes or the presence of a cast or a splint. A review of the Treatment Administration Record (TAR), dated from May 29 to June 29, 2015, indicated the licensed nurses monitored daily Resident 1's left lower extremity splint; however, there was no documentation the nurses monitored the blood circulation, by doing a capillary refill test (time taken for color to return to the area where pressure was applied to cause blanching), and there was no documentation of an assessment of the toes being warm / cool to touch, the presence/absence of pain on the toes, changes in size, presence or absence of swelling, or any other abnormality. There was no documentation regarding cast care provided to Resident 1. On June 29, 2015, at 4:15 p.m., the clinical record indicated Resident 1 went to a physician's appointment (Physician 3, primary care physician) and was found to have a dry gangrene on the left toes. The resident was transferred from the physician's office to a general acute care hospital (GACH). According to the GACH Emergency Room Physician's Progress Note, dated June 29, 2015, Resident 1 was found with Stage III/IV pressure sore (full thickness skin loss) to the left dorsum of foot, the left second toe was found with a Stage III pressure sore, and dry gangrene of all the toes of the left foot. The GACH treatment orders indicated a wound vacuum (promotes healing through negative pressure wound therapy) or skin graft for the left dorsum Stage III/IV pressure sore and a recommendation of amputation of left toes gangrene. Further review of the GACH clinical record indicated Resident 1 was transferred on July 1, 2015, to another skilled nursing facility (SNF).During an interview with the Director of Nursing (DON), on August 10, 2015, at 10 a.m., he stated Resident 1 was admitted to the facility with a splint and a cast extending from the left thigh to the foot, exposing the resident's toes. The DON, after reviewing the clinical record, stated there was no care plan developed for Resident 1's cast care and the facility had no policy and procedure addressing cast care. The DON stated Resident 1's nurse practitioner visited the resident frequently and on the nurse practitioner's last note, dated June 29, 2015, did not indicate Resident 1 had gangrene on the left toes. When asked if the treatment nurse had any documentation regarding Resident 1, the DON stated the treatment nurse would only document abnormal skin conditions if they were present. On September 1, 2015, at 2:30 p.m., during a telephone interview, Resident 1's nurse practitioner stated Resident 1 had a splint upon admission to the facility and was placed on a hard cast during the orthopedist visit (on June 3, 2015).During an interview with Licensed Vocational Nurse 1 (LVN 1), the treatment nurse, on August 10, 2015, at 11 a.m., he stated Resident 1's left leg was covered with a hard cast, and there was also a splint placed on top of the cast, while the resident's toes were exposed. When LVN 1 was asked how he monitored the resident's leg on a cast, he stated he checked the cast by placing his finger inside the cast, to check if there was a clearance of one inch from skin to cast.LVN 1 stated he elevated Resident 1's left leg, placed it on a pillow, and the resident's left toes had no discoloration and had no foul smelling odor. LVN 1 stated Resident 1's left toes were normal looking when he left the facility on June 29, 2015. LVN 1 did not indicate if blood circulation and skin temperature of the left toes were monitored. According to mayoclinic.org, April 2015, for cast care, contact the physician if: - Any increasing pain and tightness in the injured limb - Any numbness or tingling in the injured hand or foot - Any burning or stinging under the cast - Develops excessive swelling below the cast - Unable to move the toes or fingers of the injured limb or they become blue or cold - Develops a crack, soft spots or a foul odor in cast or gets the cast soaking wet and does not dry it properly - Patient says the cast feels too tight or too loose - Develops red or raw skin around the cast - Develops a fever of 101 F (38.3 C) or higherThe facility failed to provide Resident 1, who had a hard cast to the left lower extremity from the thigh to the beginning of the toes, with the necessary care and services by failing to ensure:1. The licensed nurses monitored the exposed toes of the left foot for signs and symptoms of infection (such as odor, presence of fluid or drainage and increased temperature of the area), for circulation on the toes, changes in size, color, and presence of pain on the left foot. 2. The physician's order to regarding cast care was followed. 3. A care plan was developed for the care and use of a hard cast. 4. A policy and procedure was in place regarding cast care. As a result Resident 1 developed gangrene of the left toes and a pressure sore Stage IV to the dorsum of the left foot.The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 1. |
| 970000021 |
THE REHABILITATION CENTER ON LA BREA |
940011781 |
A |
23-Oct-15 |
69GP12 |
8474 |
483.25 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.On September 28, 2015, at 11 a.m., an unannounced follow-up complaint visit was made to the facility to ensure the plan of correction was implemented.Based on observation, interview, and record review, the facility failed to ensure the licensed nurses for a resident in a sample of two (Resident 2):1. Performed a continuous monitoring of the condition of each gangrenous (dead tissue) areas Resident 2 had on the feet, describing response to treatment, color, progression of the wound, changes in size, and presence of drainage. 2. Implemented the plan of care to monitor for any skin breakdown and to report to the attending physician to obtain treatment orders. 3. Implemented the facility's policy and procedures on Non-Pressure Related Wounds and Skin Conditions to perform a complete assessment, document, and notify the physician of lack of progress and deterioration.As a result Resident 2's feet condition deteriorated when three open wounds developed on the feet, which were not provided with nursing or medical interventions for at least 11 days, from the time the podiatrist (Podiatrist 2) identified the wounds. A review of the clinical record indicated Resident 2 was initially admitted to the facility from a general acute care hospital (GACH), on August 25, 2015. The discharge diagnoses from the GACH included atrial fibrillation (rapid and irregular heartbeat), dry gangrene of the four extremities due to septic shock (life-threatening complication from an infection), vulvar (skin of the female genital area) melanoma (cancer) spread to the thyroid (gland in the neck that secretes hormones) and spleen (abdominal organ), muscular wasting, and hypertension (high blood pressure).The clinical record indicated Resident 2 also had a pressure sore (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) on the left hip, abscess (collection of pus in the tissue) to the right hip, and cellulitis (skin infection) on the right abdomen. According to the note dated 8/24/15 by Podiatrist 1, the day before discharge from the GACH, Resident 2 had dry gangrenous and cyanotic (bluish discoloration) changes particularly around digits (toes) 1 to 5 of the left foot, and 1, 3, 4, and 5 of the right foot; cyanosis/duskiness (darkness) to the left forefoot (front part of the foot); and an intact (no skin break) left plantar (sole) bulla (blister) measuring 2 centimeters (cm) by 3 cm.A review of the Minimum Data Set (MDS - a standardized assessment care and screening tool), dated September 3, 2015, indicated Resident 2 had no memory problem, could make decisions independently, and required total assistance from staff for all activities of daily living (ADLs). The section of the MDS (M1040) Other Ulcers, Wound and Skin Problems, which included infection, wound, lesions, and other foot problems, indicated there were no problems present on the feet.The physician's orders dated, August 26, 2015, and repeated on September 9, 2015, indicated to provide daily wound care to all gangrenous right and left toes, and the middle (medial) and lateral back (dorsal) areas of the left foot with Vashe (a cleansing solution), and to apply Betadine (iodine disinfectant solution), and cover with dry dressing. A review of Resident 2's Treatment Progress Notes, dated August 26, 2015, documented by Licensed Vocational Nurse 1 (LVN 1 - treatment nurse), indicated Resident 2 was admitted with all both left and right toes and both metatarsals (middle front of the feet) gangrenous, with 100 percent necrotic tissue, and foul odor. The plantar (sole) area of feet was not described. The bulla on the left sole area was not described and there was no documentation the feet had any open skin area or secretions/drainage.According to Physician 1's History and Physical (H&P) Examination, dated August 28, 2015, Resident 2 was admitted to the facility with necrotic toes (both feet), right hip abscess, and right abdominal cellulitis.A review of the care plan developed on August 28, 2015, addressing Resident 2's dry gangrenous wounds on the feet included the intervention to monitor the skin for signs and symptoms of skin breakdown, observe the skin condition, and report abnormalities. The Nursing Weekly Summary Notes dated August 31, 2015 and September 8, 15, and 22, 2015, had no documentation of a weekly assessment of Resident 2's left and right feet/toes wound condition, response to treatment, odor, drainage, and improvement or deterioration of the wounds. A review of a podiatrist evaluation (Podiatrist 2), dated 9/17/15, indicated Resident 2 had an ulcer on the right anterior right leg, the lateral border of the right hallux (big toe), medial aspect of the right great toe, and plantar aspect of the left foot (where the bulla was identified by Podiatrist 1 in the GACH as intact).On September 28, 2015, further review of the treatment records, nursing notes, and physician's order disclosed no evidence the above open wounds had been identified by the nurses and reported to the physician to obtain treatment orders. A review of treatment nurse weekly wound progress notes, since admission through September 23, 2015, disclosed no documentation of the status of each one of the wounds to determine the response to treatment, improvement or deterioration, changes in size, any abnormality, or if new wounds had developed.On September 28, 2015, at 1 p.m., Resident 2 was observed lying in bed while LVN 1 provided wound care. The resident was observed to have the open wounds with a yellowish/red drainage identified by Podiatrist 2 on 9/17/15, on the right great toe (on its side and on the bottom area) and the plantar area of the left feet. LVN 1 was observed treating the toes, but did not provide treatment to the open wounds on the right big toe or the left plantar area.On September 28, 2015, at 1:30 p.m., during an interview, LVN 1, who routinely performed the treatment to Resident 2, stated the open wounds on the right big toe had been there for two weeks and he had not notified the physician about the new open wounds and there were no treatment orders for the open areas. On September 28, 2015, at 2 p.m., during an interview, LVN 1 stated he did weekly wound evaluation of Resident 2's wounds. On September 29, 2015, at 2:30 p.m., during an interview and after reviewing Resident 2's clinical record, the Director of Nursing (DON) verified the treatment nurse had not notified the physician of the open wounds and stated the treatment nurse (LVN 1) should have notified the physician of any new wounds and the status of the feet should be evaluated daily when performing the treatment.According to the facility's policy and procedure titled, "Non-Pressure Related Wounds and Skin Conditions," upon detection of a wound, the license nurses perform a complete assessment, alert the physician, complete documentation in nursing notes / weekly skin form, and notify the physician of lack of progress or deteriorating signs and symptoms of inflammation.The facility failed to ensure the licensed nurses for a resident in a sample of two (Resident 2):1. Performed a continuous monitoring of the condition of each gangrenous (dead tissue) areas Resident 2 had on the feet, describing response to treatment, color, progression of the wound, changes in size, and presence of drainage. 2. Implemented the plan of care to monitor for any skin breakdown and to report to the attending physician to obtain treatment orders. 3. Implemented the facility's policy and procedures on Non-Pressure Related Wounds and Skin Conditions to perform a complete assessment, document, and notify the physician of lack of progress and deterioration.As a result Resident 2's feet condition deteriorated when three open wounds developed on the feet, which were not provided with nursing or medical interventions for at least 11 days, from the time the podiatrist (Podiatrist 2) identified the wounds. The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Resident 2 |
| 940000015 |
The Orchard - Post Acute Care |
940012525 |
B |
19-Aug-16 |
OXUQ11 |
7830 |
Health and Safety Code ? 1418.91. Report incident of alleged abuse or suspected abuse of a resident (a) A long-term health care facility shall report all incident 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: 1. Report immediately or within 24 hours to the Department of Public Health (State Licensing Agency), in accordance with State law and facility's policy and procedure, an allegation of physical abuse (willful infliction of injury such as hitting, pinching or grabbing) by a staff to Resident 14. Resident 14's family member (Family1) reported to the facility staff on 8/30/15 at approximately 5 p.m., an alleged physical abuse by a certified nursing assistant (CNA 2) that occurred on the night shift of 8/29/15, that resulted in bruising to the resident's left arm. The facility staff did not immediately report the alleged physical abuse to the administrator (facility abuse coordinator) until 8/31/15 at 6 p.m., after the discovery of the alleged physical abuse incident by the Department of Health survey team. On 8/31/15 at 4 p.m., during a tour of the facility conducted with the licensed vocational nurse (LVN 1), Resident 14 was observed sitting in a wheelchair with Family 1 at the bedside. Resident 14's left arm was observed with purple, reddish raised, skin discoloration measuring approximately 4 centimeter (cm) x 4 cm. On 8/31/15 at 4 p.m., during a concurrent interview, Family1 stated Resident 14 complained to her that she sustained a bruise on the left arm when the certified nursing assistant (CNA), who assisted her to the restroom on the evening of 8/29/15, grabbed her arm. Resident 14 could not recall the name of the CNA who assisted her to the restroom. Family1 stated, "I already reported it to the charge nurse yesterday evening. They said they would look into it." On 8/31/15 at 4 p.m., during a concurrent interview with Resident 14, she stated, "Yes, this is nothing." Resident 14 refused to discuss the incident further. On 8/31/15 at 4 p.m., during a concurrent interview with LVN 1, she stated she was not aware of the cause of Resident 14's bruise or if an investigation of the incident had been reported to the director of nursing (DON) or the abuse coordinator (administrator). A review of Resident 14?s clinical record indicated Resident 14 was admitted to the facility on 4/6/15, with diagnoses that included history of fall and dementia (mental disorder with symptoms of decreased intellectual functioning that interferes with normal life). A review of the Minimum Data Set (MDS), a resident assessment and care screening tool, dated 7/18/15, indicated Resident 14 was able to make self-understood and was able to understand others. The MDS indicated Resident 14 required extensive assistance (weight bearing support) with transfers, ambulation and hygiene with one person physical assist. The MDS indicated Resident 14 was incontinent (without control) of bowel and bladder. A review of Resident 14's medical record conducted with the DON on 9/1/15 at 8 a.m., indicated no documented evidence that the alleged physical abuse or bruising to Resident 14's left arm was investigated or reported by the staff to the administrator and to the Department of Public Health immediately when Family 1 reported the incident to the charge nurse the evening of 8/30/15. In a concurrent interview, the DON stated she did not receive a report about Resident 14's alleged physical abuse incident until the evening of 8/31/15, when the Department of Health survey team conducted a brief interview with Family 1. On 9/1/15 at 5:20 p.m., during an interview, the DON stated that the licensed staff or the director of staff development (DSD) did not conduct an investigation which should have been started immediately. The DON stated she would provide in-services to the staff about the facility's policy and procedure on abuse. On 9/3/15 at 6 p.m., in a written declaration and interview with LVN 2, he stated, that on 8/30/15 at approximately 4 p.m., Family 1 asked him to address Resident 14?s allegation that a staff that assisted her during the night to the restroom, pulled on her arm and left a bruise on her left arm. When LVN 2 was asked if he initiated an investigation or reported the alleged physical abuse incident to the abuse coordinator, he stated, "I did not.? He added that the registered nurse supervisor (RN 3) said she would take care of it. He further stated, ?I guess we had a misunderstanding. I endorsed to the night shift (11pm-7am) charge nurse, to change the assignment of the CNA who was caring for the resident because of the resident?s complaint." On 9/8/15 at 1:30 p.m., in an interview with CNA 2, she stated that RN 3 asked her about Resident 14's bruise and was not informed about Resident 14's bruise until 8/30/15 at about 11:45 p.m. CNA 2 stated that she assisted Resident 14 to the bathroom on the evening of 8/29/15. Resident 14 held on to CNA 2?s arm when she took her to the restroom and Resident 14did not complain to her. CNA 2?s assignment was changed on 8/30/15, night shift (11pm-7am) and she was moved to the other station. She stated that she was not suspended. In an interview with LVN 5 on 9/8/15 at 3:30 p.m., he stated he was in charge the night shift of 8/30/15 and changed CNA 2's assignment when LVN 2 told him to do so without giving him any reason .He stated that he heard from RN 3 and CNA 2 bits and pieces about Resident 14's bruise in the arm." On 9/8/15 at 3:40 p.m., in an interview, RN 3 stated that that she was informed by Family 1 that a CNA may have handled Resident 14 roughly or maybe her skin was just fragile. She told LVN 2 to take further steps and thought he understood that he was supposed to do the investigation and documentation, but he did not." RN 3 was asked if she ensured that LVN 2 reported the incident to the abuse coordinator or investigated and documented the incident, she stated, "No, but I should have." RN 3 stated, "I did not inform the supervisor because I thought she might be busy that weekend and I did not do any documentation about the family's complaint about the resident? In an interview with the abuse coordinator (administrator) on 9/9/15 at 10:30 a.m., he stated, he was not informed about the resident's complaint of alleged physical abuse, "The staff knows my number, including my cell phone number. They can call me anytime for any issues." According to the facility's policy and procedure titled, "Nursing Administration," dated 2/2008, ?all alleged violations, including injuries of unknown sources are reported immediately to the administrator and to the officials in accordance with the State Law. Unknown bruises and skin tears will be investigated to rule out abuse. The charge nurse shall immediately examine the resident and document in the medical record the findings of the examination. The facility's policy and procedure titled, "Abuse Reporting", dated 5/2007 indicated that all alleged incidents of abuse, mistreatment or neglect are to be reported to the State Licensing Agency immediately or within 24 hours. Therefore, the facility failed to: 1. Report immediately or within 24 hours to the Department of Public Health (State Licensing Agency), in accordance with State law and facility's policy and procedure, an allegation of physical abuse (willful infliction of injury such as hitting, pinching or grabbing) by a staff to Resident 14. The above violations either jointly, separately, or in any combination had a direct or immediate relationship to Resident 14?s health, safety, or security. |
| 940000015 |
The Orchard - Post Acute Care |
940012705 |
A |
1-Nov-16 |
Y9CF11 |
16425 |
CFR ? 483.25 [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. CFR ? 483.25(m) Medication Errors The facility must ensure that- [F333] CFR ? 483.25 (m) (2) Residents are free of any significant medication errors. On 7/26/16, a complaint investigation was conducted at the facility to investigate an allegation of neglect. The facility failed to: 1. Develop a plan of care for Resident 1?s cirrhosis. 2. Promptly intervene when there was a change in Resident 1?s condition 3. Ensure Resident 1 received lactulose solution, 20 grams daily as ordered by the physician. Lactulose is a medication used to reduce the amount of ammonia (nitrogen waste) in the blood of a person with liver disease. When there is excessive accumulation of ammonia in the blood it becomes toxic to the body. 4. Notify the physician when lactulose medication was not given as ordered. Resident 1 was not given the lactulose medication as ordered for six days out of two consecutive weeks, from August 3, 2015, to August 14, 2015, that resulted in Resident 1 having abnormally high ammonia blood level of 109 (reference range was 16 to 53) on August 15, 2015. Resident 1 was showing lethargy (abnormal drowsiness) from August 15, 2015, was complaining of pain, 6-7/10 (zero being no pain and ten being the worst pain) from August 17, 2015 at 8 p.m., and wanting to go to the hospital because he was not feeling well; he felt like dying. The facility did not recognize the change in Resident 1's condition and intervene promptly until Resident 1's family member (Fam 1) took Resident 1 out of the facility to the hospital on August 18, 2015, at 9:20 a.m., against medical advice (AMA), a three day delay in seeking proper medical intervention. A review of Resident 1's admission record indicated the resident was originally admitted to the facility on July 3, 2015, and re-admitted on July 16, 2015, with diagnoses that included end-stage renal failure (last stage of chronic kidney disease, when the kidneys permanently fail to function) with hemodialysis (a medical procedure to remove fluid and waste products from the blood and to correct electrolyte imbalances; accomplished by using a machine) and cirrhosis (a slowly progressing disease in which healthy liver tissue is replaced with scar tissue, and eventually preventing the liver from functioning properly). According to the Minimum Data Set (MDS), a resident assessment and care screening tool, dated August 11, 2015, Resident 1 had intact cognitive skills for daily decision making and required extensive assistance (weight bearing support) with one or two persons-physical assistance for activities of daily living. On May 5, 2016, at 12:41 p.m., during a phone interview, Fam 1 stated Resident 1 was lethargic, had shortness of breath, and his stomach was getting bigger and bigger. Fam 1 stated Resident 1 complained of abdominal pain about a week prior to August 18, 2015. On August 18, 2015, at around 8:45 a.m., Fam 1 stated Resident 1 called and was crying and said he was in trouble. Fam 1 stated on the same day she arrived at the facility, she found Resident 1 crying and saying he needed help and wanted to go to the hospital. Resident 1 was saying he felt like dying. Fam 1 stated she tried to convince the nurses to send Resident 1 to the hospital instead the licensed nurse gave her a paper to sign to release Resident 1 from the facility AMA. A review of the Progress Notes, dated August 18, 2015, at 5:52 a.m., indicated Resident 1 complained of not feeling well and was insisting on going to the hospital. It was documented the charge nurse explained to Resident 1 that his complaint was not urgent and that she would follow-up on this issue in the morning. Resident 1's vital signs were as follows: blood pressure 96/55 millimeter mercury (mmHg, normal: 120/80), temperature 98.0 degree Fahrenheit, heart rate 80 and respiratory rate 18. It was documented that registered nurse (RN 1) assessed Resident 1 and he was complaining of abdominal pain, his abdomen was tender to the touch and distended due to ascites (accumulation of fluid in abdomen) and liver cirrhosis. The Progress Notes, dated August 18, 2015, at 4:56 a.m., indicated RN 1 received a call from the police about Resident 1, who called the police department and requested paramedics to transfer him to the hospital. At 4:59 a.m., RN 1 spoke to the on-call physician and explained that Resident 1 was insisting on transfer to the hospital because he was not feeling well and has called 911 for paramedics. It was indicated that RN 1 reported to the on-call physician that Resident 1 complained of not feeling well with slight hematuria (bloody urine). The on-call physician stated Resident 1's complaint was not urgent for emergency room visit and stated would inform Resident 1's primary care physician. On May 25, 2016, at 6:49 a.m., during an interview, RN 1 stated that on August 18, 2015, at around 4:46 a.m., he received a call from the police that Resident 1 called them and asked for paramedics to transfer him to the hospital. RN 1 stated upon assessment, Resident 1's abdomen was distended and was complaining of abdomen pain. RN 1 stated he notified the on-call physician and reported that Resident 1 was not feeling well, the resident's vital signs, presence of hematuria (bloody urine), and the resident's wish to go to the hospital. The on call physician stated that Resident 1's condition was not urgent. RN 1 stated he did not inform the on-call physician of Resident 1's diagnoses, history and physical, recent laboratory results, and medications. A review of the Medication Administration Record (MAR) for August 2015 indicated Resident 1 was administered one tablet of Hydrocodone-Acetaminophen (Norco) 5/325 milligrams (mg) for pain: 1. On August 17, 2015, at 8 p.m. for pain 7/10 2. On August 18, 2015, at 12:55 a.m. for pain 6/10 3. On August 18, 2015, at 5:30 a.m. for pain 7/10 A review of the Progress Notes, dated August 18, 2015, at 9:20 a.m., indicated Fam 1 took Resident 1 out of the facility to the hospital. A review of the Physician Discharge Summary, dated August 18, 2015, indicated Resident 1 was discharged from the facility AMA. A review of Resident 1's care plans indicated there was no documented evidence that a comprehensive care plan was developed for Resident 1's diagnosis of cirrhosis. On May 25, 2016, at 7:29 a.m., during an interview and concurrent review of Resident 1?s record, RN 1 stated there was no care plan developed for Resident 1's diagnosis of cirrhosis. RN 1 stated there should have been a care plan for Resident 1's diagnosis of cirrhosis. RN 1 stated the purpose of a care plan was to plan how the resident's care and monitoring would be delivered. If there was no care plan, then the nurses would not know what to monitor. A review of Resident 1's Order Summary Report (physician's orders) for July 2015 indicated the following: 1. On July 16, 2015, for dialysis treatment at the dialysis center three times a week on Monday, Wednesday and Friday at 8: 30 a.m. 2. On July 20, 2015, to administer lactulose solution 20 grams (gm) per 30 milliliter (ml) by mouth one time a day for cirrhosis starting on July 21, 2015. 3. On July 28, 2015, for transportation pick up time at 8 a.m. on dialysis days. A review of Resident 1's clinical record indicated that the lactulose solution was scheduled for administration at 9 a.m. daily. According to the Medication Administration Record (MAR) for August 2015, the facility failed to administer lactulose solution 20 gm as ordered on the following days to Resident 1: 1. On Monday August 3, 2015. 2. On Wednesday August 5, 2015. 3. On Friday August 7, 2015. 4. On Monday August 10, 2015. 5. On Wednesday August 12, 2015. 6. On Friday August 14, 2015. According to the MAR, the reason for Resident 1 not receiving lactulose solution 20 mgs as ordered for two weeks was because of Resident 1's absence from the facility. A review of Resident 1's clinical record indicated there was no physician's order to hold lactulose solution administration during dialysis days. On May 25, 2016, at 9 a.m., during a phone interview, the licensed vocational nurse (LVN 1) stated that Resident 1 did not want to take lactulose because he would either have visitors come visit him or would keep going to the bathroom. LVN 1 stated she remembered notifying Resident 1's physician about not administering lactulose for two weeks, but could not remember if she documented it. LVN 1 stated Resident 1 had periods of altered mental status starting August 15, 2015. A review of the Progress Notes, dated August 15, 2015, at 3:32 p.m. indicated Fam 1 verbalized concern regarding Resident 1's cognitive (mental) function. The physician's order, dated August 14, 2015, at 9:58 p.m., indicated for ammonia blood level test to be performed on August 15, 2015. A review of the Diagnostic Laboratories report, dated August 15, 2015, indicated Resident 1's ammonia level was 109 (reference range was 16 to 53). According to studies on patients with cirrhosis who had minimal hepatic encephalopathy (MHE), a condition in which behavioral, psychological and neurological changes are associated with advanced liver disease, found that cognitive function and health related quality-of-life improved when they took lactulose solution. Lactulose is a drug used to help eliminate toxins such as ammonia that are normally cleared by the liver. (American Association for the Study of Liver Diseases (AASLD), March 2007 https://www.aasld.org/publications/practice-guidelines). On August 16, 2015, the physician's order indicated to increase lactulose solution of 20 gm per 30 ml from once a day to twice a day, for a total of 40 gm daily for Resident 1. On May 25, 2016, at 10:08 a.m., during a phone interview, Physician 1, who was Resident 1's primary care physician, stated she was not aware Resident 1 was not receiving lactulose for two weeks. Physician 1 stated if Resident 1 just refused or did not receive lactulose once or twice would be fine but if it was a pattern then it was important to let her know. Physician 1 stated there was no order to hold lactulose on Resident 1's dialysis days. Physician 1 stated Resident 1 should have received his lactulose after returning from dialysis. During the same phone interview, Physician 1 stated, ?If the resident really insist on going to the hospital, I would transfer because the resident knows his body more than anyone. It is very important of what and how the nurse report to me about the resident's condition and accurate assessments. We rely on their assessments. The nurse have to let us know the history and physical, diagnoses, pain characteristics, bowel movement and characteristics, laboratory results, medications, vital signs, the resident?s mental status, all those are important factors to help me determine the resident?s condition for treatment.? On May 25, 2016, at 11:10 a.m., during an interview and concurrent review of Resident 1?s record, the director of nursing (DON) stated that according to the MAR for August 2015, Resident 1 did not receive lactulose solution as ordered on August 3, 5, 7, 10, 12 and 14, 2015. The DON stated the physician should have been notified of lactulose not being administered after three attempts to administer the lactulose medication. The DON stated the lactulose administration time should have been adjusted and scheduled for administration after Resident 1's dialysis. The DON stated the medication nurses were not proactive enough to communicate to the registered nurse supervisor or the physician about the pattern of not administering lactulose. During the same interview, the DON stated RN 1 should have at least told the on call physician regarding Resident 1's history and physical, his current condition and diagnoses, and medications. The DON stated, ?Physicians heavily rely on our licensed nurses' assessments because they are not always present at the facility.? The DON stated there was no documented justification why lactulose medication was not given or refused by Resident 1. The DON stated there was no documentation that the physician was notified that lactulose medication was not given to Resident 1. A review of the hospital Emergency Department (ED) Admit Note, dated 8/18/15, indicated Resident 1 arrived to the ED with blood pressure of 85/49 mmHg. Resident 1?s abdomen was distended with positive fluid wave and diffusely (not concentrated in one area) tender to palpation. Resident 1 was diagnosed with urinary tract infection (UTI), spontaneous bacterial peritonitis (infection of ascites [fluid accumulated in the peritoneal cavity causing abdominal swelling]), and sepsis (infection spread throughout the body). Resident 1 underwent paracentesis (a needle inserted into the peritoneal cavity to remove fluid) with peritoneal fluid noted with Escherichia Coli (gram negative bacteria) with extended-spectrum beta-lactamase (ESBL-producing organisms are resistant to many classes of antibiotics, resulting in limitation of therapeutic options) on 8/18/2015. A review of Resident 1?s hospital abdomen and pelvis computerized tomography (CT), dated 8/18/15, indicated large volume of ascites, large right and moderate left pleural effusions (excess fluid accumulate in the lung space), diffuse anasarca (accumulation of watery fluid in connective tissue and cavities resulting in edema), and right greater than left lung compressive atelectasis (condition that develops when a person's lung cannot fully inflate due to foreign body occupying air space). The hospital laboratory results, dated 8/18/15, indicated Resident 1?s lactic acid (acid that forms when body breaks down carbohydrates to use for energy when blood oxygen level is low) was 40.9 (normal range 4.5-19.8 milligrams (mg)/deciliter (dL), and ammonia was 73. The ED Admit Note, dated 8/18/15, indicated Resident 1 needed to be admitted to the hospital for further management and care. A review of the facility's undated policy and procedure on Administration of Medications indicated the following: 1. The licensed nurse should enter an explanatory note on the reverse side of the MAR when medication was withheld, refused, or given other than at scheduled time. The Director of Nursing Services and the Attending Physician should be notified when two medication doses were refused or not administered. 2. When a resident is away from his or her room or unavailable during the medication pass, the charge nurse should flag the MAR (i.e., paper clips, fold down, etc.). Once the medication pass has been completed, the nurse should administer medications to missed residents. Therefore, the facility failed to: 1. Develop a plan of care for Resident 1?s cirrhosis. 2. Promptly intervene when there was a change in Resident 1?s condition 3. Ensure Resident 1 received lactulose solution, 20 grams daily as ordered by the physician. 4. Notify the physician when lactulose medication was not given as ordered. Resident 1 was not given the lactulose medication as ordered for six days out of two consecutive weeks, from August 3, 2015, to August 14, 2015, that resulted in Resident 1 having abnormally high ammonia blood level of 109 (reference range was 16 to 53) on August 15, 2015. Resident 1 was showing lethargy from August 15, 2015, was complaining of pain, 6-7/10 (zero being no pain and ten being the worst pain) from August 17, 2015 at 8 p.m., and wanting to go to the hospital because he was not feeling well; he felt like dying. The facility did not recognize the change in Resident 1's condition and intervene promptly until Fam 1 took Resident 1 out of the facility to the hospital on August 18, 2015, at 9:20 a.m., against medical advice, a three day delay in seeking proper medical intervention. The above 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 to Resident 1. |
| 940000015 |
The Orchard - Post Acute Care |
940012867 |
A |
19-Jan-17 |
1MGY11 |
19581 |
F315
?483.25(d) Urinary Incontinence
(2) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.
The facility failed to ensure residents received the necessary care and services to prevent urinary tract infections (UTI), a disease caused by microorganisms that invade the tissue of the kidneys, bladder, or urethra, by not:
1. Following its policy, titled, ?Call Light/Bell,? which indicated to answer call lights within a timely manner (3-5 minutes), and listen to the resident's request/need, and to respond to the request.
2. Following its policy, titled, ?Prevention of Urinary Tract Infection/Indwelling Urinary Catheter,? which indicated the urine collection bag will be maintained below the level of the resident?s bladder.
3. Responding to Resident 21?s call light timely which resulted in Resident 21 holding her urine for long periods of time, and having abdominal pain.
These failures resulted in Resident 21 holding her urine for long periods of time, resulting in the development of four UTIs over a six month period requiring antibiotic (used to treat infections) therapy, and receiving pain medication for dysuria (painful urination). Resident 23, who had a supra-pubic urinary catheter (a thin sterile flexible tube that is used to drain urine from the bladder inserted through a cut in the abdomen, a few inches below the navel), with a history of UTIs (five within six months) requiring antibiotics. Resident 23?s catheter bag was observed lying on Resident 23?s chest/abdomen area with the urine back flowing toward the bladder. These failures resulted in Residents 21 and 23 developing recurrent UTIs and having pain, which had the potential to result in urosepsis (a life-threatening bacterial infection, a complication of urinary tract infections).
a. During a quality of life (QOL) group interview, conducted on 11/15/16, at 11:15 a.m., with 11 alert residents in attendance, Resident 21 stated the staff does not answer her call light timely resulting in her holding her urine for long periods of time, having accidents, and not getting changed on time. During the QOL interview, the ombudsman (a patient advocate) in attendance stated on her many visits to the facility she would see the CNAs (certified nurse assistant) huddled in one area talking amongst themselves.
A review of Resident 21's Admission Face Sheet and clinical record indicated Resident 21 was a XXXXXXX year-old female who was admitted to the facility on XXXXXXX16. Resident 21's diagnoses included Stage IV chronic kidney disease (advanced kidney damage), hypertension (high blood pressure), and a history of multiple urinary tract infections.
A review of Resident 21's Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 8/9/16, indicated Resident 21 was able to be understood and understand others. Resident 21's Brief Interview for Mental Status (BIMS) score was 9 (8-15=interviewable). According to the MDS, Resident 21 required limited assistance with a one-person physical assist for walking, transferring, and toilet use.
On 11/16/16 at 2:55 p.m., during an interview, Resident 21 stated she urinated a lot and had a history of UTIs. Resident 21 stated she waits a long time for the certified nursing assistants (CNAs) to respond to the call light when she wanted to go to the bathroom. Resident 21 stated it hurts her abdomen when she had to wait long to urinate. Resident 21 stated sometimes she had to wait so long for the CNA to come and assist her to the bathroom she would wet herself. Resident 21 stated during her eight month stay at the facility the CNAs would sometimes come in and turn off the call light and not assist her. Resident 21 stated the CNAs would say, ?I'll get your nurse, but no one ever comes back." When Resident 21 was asked how she felt when it happened she stated, "It doesn't make me feel too good.?
A review of Resident 21's nurse?s notes/clinical record indicated Resident 21 had four UTIs over a six month period from (4/2016-10/2016), on 4/21/16, 6/1/16, 8/21/16, and 10/10/16. A review of Resident 21's Medication Administration Record (MAR), for the month of 4/2016, from 4/1/16-4/30/16, indicated Resident 21?s antibiotic therapy was started on 4/21/16 at 2:21 p.m., of Ciprofloxacin ([Cipro] an antibiotic used to treat a number of bacterial infections) 250 milligram (mg) two times a day (BID) for 10 days for UTI.
A review of Resident 21's laboratory urinalysis ([UA] analysis of urine to detect the presence of disease) results, dated 6/1/16, and timed at 11:41 a.m., indicated the leukocyte esterase (a type of enzyme produced by white blood cells [indicative of UTI]) result was out of range at 2+ (normal reference range [NRR] results should be negative). Resident 21's white blood cell ([WBC] indicative of the presence of an infection if elevated) count on the same date was elevated at 11-20 (NRR should be 0-5).
A review of Resident 21's physician orders, dated 6/1/16, and timed at 9 p.m., indicated Resident 21 was started on another antibiotic. The physician ordered ceftriazone sodium (an antibiotic used to treat bacterial infections) solution one (1) gram (one thousand milligrams) intravenously ([IV] into the vein) for 10 days at bedtime for UTI.
A review of Resident 21's laboratory UA results, dated 8/20/16, and timed at 6:02 p.m., indicated the leukocyte esterase was 3+ (NRR=should be negative), the WBC count was >50 (greater than 50 ), and the bacteria was moderate (NRR should be negative).
According to a nurses' note, dated 8/20/16, and timed at 10:29 p.m., Resident 21 complained of lower abdominal discomfort and had dysuria (pain while urinating). According to Resident 21's MAR, for the month of 8/2016, Resident 21 received a new order for medication on 8/21/16 at 1 p.m., for Augmentin (an antibiotic used to treat a bacterial infections) 500 mg three times (TID) a day for 10 days.
A review of Resident 21's laboratory UA results, dated 10/3/16, and timed at 8:58 a.m., indicated nitrite was present (which is indicative of a UTI ) was positive (NRR=should be negative), leukocyte esterase was 3+, WBC count was >50, and the bacteria was few. Resident 21's MAR, for the month of 10/2016 indicated Resident 21 received Augmentin (an antibiotic used to treat a number of bacterial infections) 250-125 mg TID.
A review of Resident 21's UA results, dated 10/24/16, and timed at 9:49 a.m., the leukocyte esterase was noted as trace, the WBC count was elevated at 11-20, and the bacteria was few. Resident 21's urine culture (a test to find and identify germs [usually bacteria] that may be causing a urinary tract infection), dated 10/27/16, and timed at 3:32 p.m., indicated that two organisms were present in Resident 21's urine, Escherichia coli (a germ, or bacterium, that lives in the digestive tracts of humans and animals) and Providencia stuartii (a bacterial species isolated from urinary tract infections and from small outbreaks and random cases of diarrheal disease).
A review of Resident 21's MAR, for the month of 10/2016, indicated Resident 21 received Pyridium (a medication used to treat pain, burning, increased urination, and the increased urge to urinate) tablet 100 mg TID for dysuria (painful urination). The MAR, also indicated Resident 21 was started on cranberry tablets (is acidic and can interfere with unwanted bacteria in the urinary tract) 450 mg, every day for prophylaxis (prevention of UTI), started on 10/26/16 at 2:38 p.m.
On 11/17/16 at 10:20 a.m., during an interview, Resident 21 stated she waited at least 10-15 minutes for a CNA to assist her to the bathroom. Resident 21 stated she had pains in her abdomen sometimes and it started since she had been in the facility. Resident 21 stated, "I think my pain is happening because they make me wait so long."
A review of an article by WebMD, titled ?Your Guide to Urinary Tract Infections (UTIs),? indicated holding urine in the bladder too long can boosts the risks of UTI at http://www.webmd.com/women/guide/your-guide-urinary-tract-infections
On 11/17/16 at 10:35 a.m., during an interview, a registered nurse (RN 3) stated a resident's call light should be answered as soon as possible, even if it was not that CNA?s resident. When RN 3 was asked what could happened if a resident hold their urine for long periods of time, RN 3 stated, ?A backflow of urine could happen, which could cause an infection [sic].?
On 11/17/16 at 10:41 a.m., CNA 7 was asked how long should it take for a resident's call light to be answered after it was activated; CNA 7 stated the resident should not wait longer than one minute. CNA7 was asked if 10-15 minutes was a long time to wait for assistance, CNA 7 stated, ?Fifteen minutes is too long. Five minutes is too long. My coworkers should go, if I can?t answer it (the call light)."
A review of Resident 21's care plan, dated 8/20/16, and titled, ?At risk for UTI related to dysuria, abdominal discomfort and scanty urine," indicated the staff?s interventions included to check Resident 21 for incontinence (a loss of control of the bladder), encourage adequate fluid intake, monitor intake and output, and obtain vital signs as ordered per the facility?s protocol.
A review of Resident 21's care plan, dated 10/10/16, titled, ?On antibiotic therapy related to UTI,? indicated the staff?s interventions included to administer medication as ordered, and noted that any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions, to monitor every shift for adverse (harmful) reaction, observe for possible side effects every shift, and report pertinent lab results to the physician.
On 11/17/16 at 12:29 p.m., during an interview with a physician (Physician 1), a nephrologist (a physician who specialized in kidney care and treating diseases of the kidneys), was asked if holding urine can result in UTI and Physician 1 stated, ?It is advisable to void (urinate) frequently and older residents may have stress incontinence (the involuntary leakage of urine) so they may want to train the resident to void timely at least every four hours. Holding urine can be a complicating factor to develop a UTI. "
On 11/18/16 at 9:22 a.m., during a telephone interview, Resident 21's family member stated Resident 21 told him that she had been holding her urine. Resident 21's family member stated that he had witnessed the staff take a long time to take Resident 21 to the bathroom. Resident 21's family member stated Resident 21 would wait up to 15 minutes sometimes. Resident 21's family member stated, ?There's a trick to it. When the light goes on, they (staff) and come turn it off, because it's on a timer and leave and no one comes back to assist her (Resident 21). I have seen it."
On 11/18/16 at 9:48 a.m., during an interview, the facility?s director of staff development (DSD) stated that the call lights are on a timer and when the resident pushes the call light, the timer starts.
A review of the facility's policy titled, "Call Light/Bell," with a revision date of 5/2007, indicated the staff should answered the call light within a reasonable time (3-5 minutes), listen to the resident's request/need, and to respond to the request.
b. On 11/17/16 at 9:59 a.m., Resident 23 was observed in bed with the urinary catheter not clamped, draining straw-colored urine in the bag and catheter tubing. The catheter?s bag was lying on top of Resident 23's chest/abdomen area. Resident 23 stated she was waiting for the certified nursing assistant (CNA 6) to come back with the lift to transfer her to the wheelchair. The urine was observed in the catheter tubing back flowing upward toward Resident 23?s bladder. Resident 23 stated the CNAs always placed the catheter bag on top of her for transferring.
A review of an article by Drugs.com, titled ?Foley Catheter Placement and Care,? indicated the drainage bag should be below the level of the waist, which helps the urine from moving back up the tubing and into the bladder. The article indicated the tubing should not be looped or kinked, because it can also cause urine to back up and collect into the bladder https://www.drugs.com/cg/foley-catheter-placement-and care.html.
At 10:03 a.m., on 11/17/16, a registered nurse (RN3) was called into Resident 23's room to see the resident's catheter bag placement above her bladder. RN 3 came to Resident 23's bedside and stated the catheter should not be higher than the bladder. Resident 23 stated, "It?s okay, this is how we do the transfer to the wheelchair." RN 3 stated Resident 23 had a history of UTIs and was receiving prophylaxis (prevention) antibiotics for recurrent UTIs.
On 11/17/16 at 11:05 a.m., during an interview, CNA 6 stated she had cared for Resident 23 for over three years, because the resident was particular what CNA cared for her due to the resident's pickiness and routine. CNA 6 stated she knew Resident 23's habits and how the resident liked things. CNA 6 stated she gets Resident 23 up in the wheelchair every day and she understands the importance of the urinary catheter bag placement being below the bladder to prevent backflow and UTIs, because she was just in-serviced by RN3.
A review of Resident 23's Admission Face Sheet indicated Resident 23 was a 67 year-old female who was admitted to the facility on XXXXXXX 04. Resident 23's diagnoses included multiple sclerosis (disease involving damage to the nerve cells in the brain and spinal cord), muscle weakness, complete paraplegia (complete paralysis [loss of muscle function ] of the lower half of the body), orthostatic hypotension (low blood pressure when standing up), generalized anxiety disorder (feelings of fear), major depressive disorder (persistent feelings of sadness), and gastro esophageal reflux disease ([GERD] a disorder where the stomach?s digestive juices flows back up and caused heartburn).
A review of Resident 23?s Minimum Data Set (MDS), an assessment and care screening tool, dated 8/15/16, indicated Resident 23 had a Brief Interview for Mental Status (BIMS) score of 14 ([cognition intact] had the ability to make decisions). According to the MDS, Resident 23 had the ability to understand and be understood. The MDS, under Section G0110 B., for Functional Status (ADL Self Performance), indicated Resident 23 required an extensive assistance of a two-plus person physical assist with bed mobility and transferring. The MDS indicated Resident 23 was incontinent (inability to control) of bowel/bladder and had a supra pubic catheter.
The following are Resident 23?s urine culture results:
1. On 12/29/15, a urine culture was positive for the organism Morganella Morganii. Resident 23 started on Ertapenem 1 gm IV (into the vein [used to treat severe infections of the skin, lungs, stomach, pelvis, and urinary tract]) piggy back given for seven days.
2. On 2/9/16, a urine culture was positive for the organisms Proteus mirabilis > (greater than) 100,000 colonies/ml. A handwritten note on the lab results indicated 10 doses of oral Amoxil 500mg were ordered until culture and sensitivity results.
3. On 3/8/16, a urine culture was positive for Proteus mirabilis (>100,000 colonies/ml) and an Enterococcus species (50,000 colonies/ml). According to the handwritten note on the UA report, Resident 23 was started on Zosyn (an antibiotic) 3.375g every six hours for 10 days.
4. On 5/10/16, a urine culture was identified to have many bacteria and was positive for the organism Klebsiella pneumoniae (>100,000 colonies/ml) and Staphylococcus aureus (50,000 colonies/ml).
5. On 6/24/16, a urine culture/chemistry indicated Resident 23?s urine was positive for 3+ Leukocyte Esterase (indicative of a UTI), turbid in appearance (cloudy, opaque or thick), red blood cell >30, white blood cell >50, bacteria few, and budding yeast. The urine culture was positive for Proteus mirabilis. On 6/27/16, Amoxicillin (an antibiotic) 500 mg was started TID for 10 days.
A review of Resident 23's physician's orders via a telephone order, dated 6/27/16, indicated Amoxicillin capsule 250 milligrams (mg) was ordered by the physician to be administered by mouth once a day for UTI prophylaxis (prevention) for 60 days. Another physician?s order, dated 9/8/16, indicated to continue the Amoxicillin 250 mg for a total of 90 days.
A review of Resident 23?s care plan, initiated on 6/27/16, identified Resident 23 at risk for a potential problem with receiving antibiotic therapy related to UTI prophylaxis. The goal indicated Resident 23 would be free of any discomfort or adverse side effects of the antibiotic therapy through a review date of 11/24/16. The staff interventions included to administer medication (antibiotic) as ordered.
A review of a medication regimen review (MRR) for Resident 23, conducted by the facility?s pharmacist consultant (PC), dated 8/8/16, indicated that an antibiotic used for prophylaxis was not recommended due to the risk of bacteria developing resistance to the antibiotic. The PC documented, ?Please evaluate for a stop date.?
A review of Resident 23's Medication Administration Records (MARs) for the months of 8/2016, 9/2016, and 10/2016, indicated Resident 23 continued to receive the prophylaxis Amoxicillin every day until 10/8/16, two months after the PC recommended discontinuing the antibiotic.
On 11/17/16 at 2:15 p.m., during an interview, the Minimum Data Set Nurse (MDS Nurse 1) stated they provided teaching to Resident 23 regarding the level of the indwelling urinary catheter bag placement after it was brought to their attention. MDS Nurse 1 stated Resident 23 was adamant about placing the catheter bag on her chest/abdomen area, since it was her routine throughout the years. MDS Nurse 1 stated Resident 23 stated, "I have been here for over 13 years doing the same thing, and I am not going to change anything!" The MDS Nurse stated the staff met and decided to have Resident 23's urinary catheter clamped during transfer to avoid the urine backflow into Resident 23?s bladder.
A review of the facility's undated policy, titled, "Prevention of Urinary Tract Infection/Indwelling Urinary Catheter,? indicated an unobstructed downward flow will be maintained at all times unless the catheter is clamped for a procedure. The policy also indicated the urine collection bag will be maintained below the level of the bladder.
The facility failed to ensure residents received the necessary care and services to prevent urinary tract infections (UTI), a disease caused by microorganisms that invade the tissue of the kidneys, bladder, or urethra, by not:
1. Following its policy titled, ?Call Light/Bell,? which indicated to answer call lights within a timely manner (3-5 minutes), and listen to the resident's request/need, and to respond to the request.
2. Following its policy titled, ?Prevention of Urinary Tract Infection/Indwelling Urinary Catheter,? which indicated the urine collection bag will be maintained below the level of the resident?s bladder.
3. Responding to Resident 21?s call light timely which resulted in Resident 21 holding her urine for long periods of time and having abdominal pain.
The above violations presented either imminent danger that death or serious harm would result or a subsequent probability that death or serious physical or mental harm would result. |
| 940000015 |
The Orchard - Post Acute Care |
940012868 |
B |
19-Jan-17 |
1MGY11 |
8017 |
CLASS B CITATION-ABUSE/FACILITY NOT SELF REPORTED Health and Safety Code ?1418.91. Report incident of alleged abuse or suspected abused of a resident. (a) A long-term health care facility shall report all incident 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: 1. Follow its policy titled "Abuse Prevention," which indicated all alleged abuse, mistreatment or neglect should be reported to the State Licensing Agency immediately, or within 24 hours. 2. Report the alleged abuse of Resident 19 to the administrator, as stipulated in their policy. This deficient practice resulted in the facility not following its policy regarding reporting abuse allegations and had the potential for Resident 19 to have ongoing abuse and resulted in another resident (Resident 23) feeling unsafe. On 11/15 /16, at 10 a.m., during a quality of life (QOL) group interview, in the presence of 11 alert residents, the residents were asked if they were aware of any instances when a resident was abused and/or neglected. Resident 23 stated, "Yes a resident (Resident 19) was seen being abuse by the resident's family member, just yesterday." Resident 23 stated the incident occurred during activities in the presence of the activity's staff, while Resident 19 was playing. Resident 23 stated the family member pulled Resident 19's chair out of the circle and scolded her. Resident 23 stated, "It did not feel good seeing it." At 7:35 a.m., on 11/17/16, during an interview, the facility's activity director (AD) stated Resident 19's family member (FM) visited Resident 19 every day and was really involved in Resident 19's care/activities. The AD stated one of the residents (Resident 23) told her three days prior (Monday, 11/14/16) that Resident 19's FM was being mean toward Resident 19. The AD stated Resident 23 stated Resident 19 was participating in an activity where she would toss rings and she could not do it, and the FM took Resident 19 out of the circle of the activity and scolded her. The AD stated she did not report the incident to anyone, but should have because it was the facility's policy. The AD stated she did not think anything of it, because she did not think Resident 19's FM would abuse her. The AD stated Resident 19's FM became upset because Resident 19 did not understand the game. On 11/17/16 at 9:30 a.m., the activity assistant (AA) stated she was in the room conducting the activity during the incident between Resident 19 and the FM. The AA stated initially Resident 19 refused to play the ring toss game and then she played, but could not toss the ring well and one of the rings struck her (AA). The FM took Resident 19 out of the circle and turned her wheelchair around and told Resident 19 her behavior was not acceptable. The AA stated Resident 19 did not throw the ring purposely to strike her. The AA stated she reported the incident to her supervisor (AD) that same day, because a resident (Resident 23) complained that the FM was being rude and aggressive toward Resident 19. The AA stated the AD told her she would follow-up and report the allegation to the administrator. At 9:59 a.m., on 11/17/16, during an interview, Resident 23 stated she was in the activity room on Monday, 11/14/16, and saw Resident 19's FM take her out of the activity circle, turned her wheelchair around and was face to face with Resident 19 and "scolded" her. Resident 23 stated the FM scolded Resident 19 because she could not do the ring toss. Resident 23 stated Resident 19's FM visited the resident every day. Resident 23 stated, "So maybe she is just tired and stressed out." Resident 23 stated she felt bad seeing the incident, especially since this was not the first time the FM had been rude and aggressive toward Resident 19. Resident 23 stated she felt it was necessary to report the incident to the AD. A review of Resident 23's Admission Face Sheet indicated Resident 23 was a 67 year-old female who was admitted to the facility on XXXXXXX Resident 23's diagnoses included multiple sclerosis (disease involving damage to the nerve cells in the brain and spinal cord), muscle weakness, complete paraplegia (complete paralysis of the lower half of the body), orthostatic hypotension (low blood pressure when standing up), generalized anxiety disorder (feelings of fear), major depressive disorder (persistent feelings of sadness), and gastro esophageal reflux disease ([GERD] a disorder where the stomach's digestive juices flows back up and caused heartburn). A review of Resident 23's Minimum Data Set (MDS), an assessment and care screening tool, dated 8/15/16, indicated Resident 23 had a Brief Interview for Mental Status (BIMS) score of 14 ([cognition intact] ability to make decisions). According to the MDS, Resident 23 had the ability to understand and be understood. A review of Resident 19's Admission Face Sheet indicated Resident 19 was an 89 year-old female who was admitted to the facility on XXXXXXX, and readmitted on XXXXXXX. Resident 19's diagnoses included urinary tract infection ([UTI] an infection in any part of the kidneys, ureters, bladder and urethra), chronic kidney disease (progressive loss in kidney function over a period of time), Alzheimer's disease (most common cause of dementia, a gradual decrease in the ability to remember), anemia (deficiency of red blood cells or of hemoglobin in the blood, resulting in pale skin and weariness), falling with syncope (a short loss of consciousness and muscle strength, and muscle weakness). A review of Resident 19's quarterly Minimum Data Set (MDS), a resident assessment and care screening tool, dated 8/17/16, indicated Resident 19 had memory problems, impaired decision-making, but was able to make needs known and understand others. According to the MDS, Resident 19 was assessed as being dependent with bed mobility, transferring, locomotion on and off the unit, requiring extensive assistance with eating and with personal hygiene. A review of the facility's abuse in-services, dated 7/8/16 and 8/11/16, indicated the AD attended the in-services. At 11:05 a.m., on 11/17/16, during an interview, Resident 23?s primary certified nurse assistant (CNA 6), who worked with Resident 23 for over 3 years, stated Resident 23 was cooperative and got along well with staff and peers. CNA 6 stated Resident 23 was credible and if she (Resident 23) stated something happened, she would believe her. On 11/17/16, at 11:23 a.m., during an interview, the administrator stated the AD was supposed to report the alleged verbal abuse immediately, as per the facility's policy. The administrator stated she started the abuse investigation regarding the allegation. The administrator presented a "Counseling/Disciplinary Notice," dated 11/17/16, indicating the AD was written-up and suspended for violation of the facility's policy and procedure of not reporting the alleged abuse. A review of the facility's policy, revised on 2/2008, titled "Abuse Prevention," indicated under the Protection; if a resident incident was reported, discovered or suspected, where the health, welfare or safety of the resident was involved, the facility should follow steps to prevent further potential abuse while the investigation is in progress. The policy also stipulated all alleged abuse, mistreatment or neglect should be reported to the State Licensing Agency immediately or within 24 hours. The facility failed to: 1. Follow its policy titled "Abuse Prevention," which indicated all alleged abuse, mistreatment or neglect should be reported to the State Licensing Agency immediately, or within 24 hours. 2. Report the alleged abuse of Resident 19 to the administrator, as stipulated in their policy. The above violation had a direct relationship to the health, safety, or security of patients. |
| 940000015 |
The Orchard - Post Acute Care |
940012869 |
B |
19-Jan-17 |
1MGY11 |
8693 |
F241 ?483.15(a) - Dignity The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The facility failed by not: 1. Ensuring two residents, Residents 21 and 27 were treated with respect and dignity. 2. Following its policy, titled, ?Dignity and Respect,? which indicated residents should be treated with kindness, dignity, and respect. 3. Following its policy, titled, ?Call Light/Bell,? which indicated to answer call lights within a timely manner (3-5 minutes), and listen to the resident's request/need, and to respond to the request. These failures resulted in Resident 21, who was continent (ability to control) of bowel and bladder, but was made to wear diapers at night and was told by the staff to urinate (act of urinating) in her diaper, which made her feel unhappy. Resident 27, while teary-eyed and wanting to go home, stated she used the bedpan (a receptacle used by a bedridden patient as a toilet) and complained the staff would leave her on the bedpan for long periods of time, which resulted in Resident 27 having back pain. a. On 11/15 /16, at 10 a.m., during a quality of life (QOL) group interview, with 11 alert residents, three (Residents 20, 21, and 22) of the 11 residents stated their call lights were not being answered timely. Resident 22 stated she does not get changed timely. Resident 21 stated that one of the facility?s nursing assistants (CNAs), during the nightshift, told her several times to urinate in her diaper when she put her call light on for assistance to go to the bathroom. Resident 21 stated the CNA told her because she was at risk for falls and did not want Resident 21 to stand up. Resident 21 stated when she urinated in her diaper it made her feel uncomfortable and unhappy. A review of Resident 21's Admission Face Sheet and clinical records indicated Resident 21 was a XXXXXXX year-old female, who was admitted to the facility on XXXXXXX. Resident 21's diagnoses included Stage 4 chronic kidney disease (advanced kidney damage), hypertension (high blood pressure), and a history of multiple urinary tract infections ([UTIs] an infection of the urinary tract that caused urgency, pain, and a burning feeling upon urination). A review of Resident 21's Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 8/9/16, indicated Resident 21 was able to be understood and understand others. Resident 21 had a Brief Interview for Mental Status (BIMS) score of 9 (8-15=inter-viewable). According to the MDS, Resident 21 required limited assistance with a one-person physical assist for walking, transferring, and toilet use. On 11/16/16 at 2:55 p.m., during an interview, Resident 21 stated she urinates a lot, and had to wait long periods of time for the CNAs to come and assist her to the bathroom, which resulted in Resident 21 holding her urine and having pain. On 11/17/16 at 10:20 a.m., during an interview, Resident 21 stated, ?The CNAs put diapers on me at night, ?Just in Case.? Resident 21 also stated at night that the CNAs would encourage her to urinate in her diaper, because they do not want her to get up and fall. Resident 21 stated she felt hopeless and bad. At 10:35 a.m., on 11/17/16 a registered nurse (RN 3) was questioned regarding what his thoughts were on telling a resident, who was continent and goes to the bathroom, to urinate in their diaper. RN 3 replied that it was not right and residents had the right to choose whether they want to go to the bathroom, use a bedpan, and/ or bedside commode (portable toilets). On 11/17/16 at 10:41 a.m., a certified nursing assistant (CNA 7) was asked if she was familiar with Resident 21. CNA 7 stated that she was familiar with Resident 21 and her preferences. CNA 7 was asked if she would ever encourage a resident to urinate in their diaper, CNA 7 stated she would never say that and it is inappropriate, especially if a resident was alert, and can go to the bathroom. On 11/18/16 at 9:48 a.m., the director of staff development (DSD) was asked if certified nursing assistants would encourage a resident to urinate in their diaper if they normally go to the restroom. The DSD replied, ?They would get in trouble. It's not appropriate.? The DSD also stated that it would be an automatic write up. When the DSD was asked if residents that go to the bathroom during the day should be afforded the same opportunity to go to the restroom during the night, the DSD replied, ?Definitely.? b. On 11/14/16 at 7:31 a.m., during the facility?s initial tour, Resident 27 was observed lying on the bed. Resident 27 was alert, talking about her daily activities and expressing concerns regarding her care. A review of Resident 27?s Admission Face Sheet, indicated Resident 27 was a 55 year-old female, who was newly admitted to the facility on XXXXXXX. Resident 27?s diagnoses included urinary tract infection (when bacteria enters the urinary tract), generalized muscle weakness, hypertension (abnormal high blood pressure) difficulty walking, cerebral vascular accident ([CVA] death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired) with right sided weakness, and congestive heart failure ([CHF] severe failure of the heart to function properly). A review of Resident 27's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/5/16, indicated Resident 27 was alert with cognition intact and had a Brief Interview for Mental Status (BIMS) with a score of 13 (9-15 score is interview-able). According to the MDS, the resident was assessed as requiring extensive assistance with personal hygiene, dressing, bathing and toileting. The MDS indicated Resident 27 was frequently incontinent (inability to control) of bowel and bladder. A review of the physician?s orders dated 11/5/16, indicated Resident 27 was receiving Aldactone 50 milligrams (mg), as well as Lasix 20 mg daily, both are diuretic medications, which results in increased urinary output. During an interview on 11/17/16 at 7:35 a.m., Resident 27 tearfully stated, ?They take a long time to change my diaper. They come much later after being called. The certified nurse assistants (CNA) leave me on the soiled bed pan for a long time, which resulted in my back hurting. I feel bad about it, I feel like a bother. I don't want to stay here, I want to go home.? On 11/17/16 at 7:42 a.m., Resident 27 gestured to come to her bedside and she stated, ?Please, I need my diaper changed.? A licensed vocational nurse (LVN 5) was called into Resident 27?s room and was told that Resident 27 was requesting a diaper change. LVN 5 was observed changing Resident 27?s diaper and a bath towel was observed in between Resident 27?s legs and the diaper. The towel was soiled, but the diaper was dry. LVN 5 stated, ?A towel is not supposed to be there (between the legs) and I will speak to the CNA immediately.? On 11/17/16 at 8:32 a.m., during a subsequent interview, LVN 5 stated that bed pans are to be taken away immediately after use and it was not normal to put a towel between a resident?s legs at any time. At 12:05 p.m., on 11/17/16, during an interview, CNA 9 initially denied placing a towel between Resident 27?s legs, but then stated, ?It is a habit of mine to place a towel on top or between the resident?s legs to prevent the urine from leaking onto the diaper.? A review of the facility's policy titled, ?Dignity and Respect,? with a revision date of 5/2007, indicated that all residents should be treated with kindness, dignity, and respect and that staff should display respect for the resident when caring for them as a constant encouragement of their individuality and dignity as human beings. A review of the facility's policy titled, ?Call Light/Bell,? with a revision date of 5/2007, indicated the staff should answered the call light within a reasonable time (3-5 minutes), listen to the resident's request/need, and to respond to the request. The facility failed by not: 1. Ensuring two residents, Residents 21 and 27 were treated with respect and dignity. 2. Following its policy, which indicated residents should be treated with kindness, dignity, and respect. 3. Following its policy, which indicated to answer call lights within a timely manner (3-5 minutes), listen to the resident's request/need, and to respond to the request. The above violations caused or occurred under circumstances likely to cause significant humiliation indignity, anxiety, or other emotional trauma to patients. |
| 950000013 |
THE ROWLAND |
950008909 |
B |
13-Jan-12 |
XN8F11 |
5199 |
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.Based on observations, interviews and record reviews, the facility failed to: 1. Report an unusual occurrence about Patient 2, who has dementia, and a history of wandering out of the nursing facility and sustaining injuries, which required evaluation at a general acute care hospital (GACH).On December 29, 2011, at 9:40 a.m., an unannounced complaint investigation was conducted. During a tour of the facility on December 29, 2011 at approximately 10:00 a.m., Patient 2 was observed with a right forehead bump bruise approximately 4 x 4 centimeters (cms), right scalp hematoma (collection of blood outside the blood vessel), right eye bruise , and bruising of the whole side of the right face down to the neck.On December 29, 2011, a review of Patient 2?s clinical record (Face sheet) indicated the patient was a 90 year-old female admitted to the facility on December 14, 2010. The patient?s diagnoses included dementia (loss of brain function that affects memory, thinking, judgment, and behavior), hypertension (high blood pressure), osteoarthritis (joint disease), arthritis (joint pain and stiffness) bilateral of the knees, and diabetes (high blood sugar). The Quarterly Minimum Data Set (MDS), a standardized assessment and care screening tool, dated October 4, 2011, indicated the patient was able to make herself understood and understand others. According to the MDS, the patient required one-person extensive assistance with walking in the facility. In addition, the MDS indicated the patient required corrective lenses for seeing fine detail, including regular print such as in newspapers/books. On December 30, 2011, a review of Patient 2?s fall risk assessment, dated October 10, 2011, indicated the patient was disoriented x3 (confused as to time, place, and person) at all times. The fall risk assessment further indicated the patient was at high risk for falls, indicating there was balancing problems while standing, walking, and Patient 2 required a use of an assistive device (i.e., cane, wheelchair, and walker). A review of a nurse?s note, dated November 22, 2011, during the 7a.m. to 3 p.m. shift, indicated the patient had periods of confusion and episodes of wandering around, trying to leave the facility. The nurse?s note, indicated the staff had spoken with Patient 2?s daughter about the patient trying to leave the facility.A review of the facility fax activity report from December 16, 2011 to December 30, 2011, indicated a document was faxed over to Department of Public Health on December 30, 2011, which was 11 days after the patient went missing from the facility. During an interview, on December 29, 2011, at 10 a.m., Patient 2 was asked how she got the bruises on her face, ?I don?t know, but it hurts a lot.? Patient 2 was asked if she knew where she was or what today it was, and she responded, ?I don?t know.? On December 30, 2011, at 10:45 a.m., the case manager stated Patient 2 was found on December 19, 2011, the same night she went missing. The case manager stated the patient was found about 20 minutes away in walking about half a mile.? When she was asked if anyone reported the incident to Department of Public Health the next day, she stated, ?No.? When asked if Patient 2 have problems of wandering before, she stated, ?No.? During an interview, on December 30, 2011, at 11:15 a.m., the director of nursing, (DON) when asked what was the facility?s policy of reporting unusual occurrence, she stated, ?We would need to call the family, physician, and the Department of Health.?During an interview, on December 30, 2011, at 12:05 p.m., the administrator stated he may have faxed an incident report to Department of Health on December 21, 2011. When he was asked if he had the fax confirmation, he responded ?No.? Ten minutes into the interview, the administrator recanted his statement and stated, ?I know better, I should have reported it to the Department of Public Health, so I faxed over an incident report on December 30, 2011.The facility failed to: 1.Report an unusual occurrence of Patient 2, who has dementia, wandering out of the nursing facility and sustaining injuries, which required evaluation at a general acute care hospital (GACH). The violation had a direct or immediate relationship to patient health, safety or security of Patient 2. |
| 970000066 |
THE CALIFORNIAN - PASADENA CONVALESCENT HOSPITAL |
950009266 |
B |
18-May-12 |
0B6111 |
11111 |
F223 483.13 (b) Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion.On February 28, 2012, at 3:15 p.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding an allegation of staff to resident abuse.Based on observation, interview, and record review, the facility failed to ensure that Resident A was free from physical abuse by Employee 1, who grabbed her arm forcefully and tightly, and stole her wedding ring off of her finger. And as a result, Resident A complained of pain, sustained two large hematoma?s to the right forearm, and was transferred to the acute hospital emergency room for evaluation.On June 10, 2008, the Department received a faxed report from the facility that indicated that on 6/6/08, at 12:50 p.m., Resident 1 had sustained a hematoma (bruise) to her left forearm, while Employee 1 was trying to change her clothes. The report further indicated that Employee 1 stated that ?Resident 1 was fighting back and was trying to bite her.? A review of the admission and discharge Summary indicated that Resident 1 was a 98 year old female who was admitted to the facility on 3/10/05, with diagnoses that included senile dementia, degenerative joint disease, and osteoporosis. The Minimum Data Set (MDS- an assessment and care planning tool) dated February 25, 2008, indicated that the resident had short and long term memory problem, was severely impaired in cognitive skills for daily decision making and required limited assistance with one person physical assistance from staff for bed mobility, dressing, toileting use, personal hygiene, and bathing. The MDS further indicated that Resident 1 had no bruises or abrasions and exhibited no signs of physically abusive behavior or resistance to care. A review of the licensed nurse?s progress notes dated 6/6/08, at 12:50 p.m. indicated that Employee 4 reported to Employee 5, that there was a bruise on Resident 1?s left forearm. The bruise was described as two hematoma sites, which were raised and elevated, with a purple discoloration. The resident had a hematoma on the middle of her left forearm which measured 3 by 3 centimeters and another hematoma on the middle of her left forearm which measured 4 by 4 centimeters over 10 centimeters by 10 centimeters. Both hematomas were described as being raised and elevated with a purplish discoloration. A review of the facility?s Accident Investigation Report dated June 6, 2008, indicated that Resident 1 had sustained a hematoma to the left forearm. The hematoma was described as a large hematoma to the left arm, which spread to the entire forearm from the wrist to the elbow and had dark red bruising and a puncture mark on the outer aspect of the mid-forearm. The report quoted the resident as saying, ?That one, we don?t know too well did this to me?, and, ?Where is my engagement ring with the stone?? The facility?s interview indicated that Employee 1 had claimed that Resident 1 was fighting and biting while she was trying to change her pants. Employee 1 grabbed Resident 1?s arm to stop her. The report further indicated that Employee 1 was immediately suspended on 6/6/08, and subsequently terminated on 6/12/08. A review of Employee 1?s file revealed that she was hired by the facility on May 27, 2008, and had only worked for the facility for ten days. The employee file did not contain a verification of Employee 1?s CNA Certification and any documented evidence that a criminal background check was done prior to being hired.A review of the ?Progressive Discipline Verbal Counseling Verification? form dated 6/6/08 indicated that Employee 1 was verbally counseled regarding the incident and was told that Resident 1 had a bruise on her left forearm and that the facility residents were not to be held tightly. It further noted that when a resident is combative the nurse aide is to seek assistance from other staff to help in providing care for the resident.The Termination Notice for Employee 1 dated 6/12/08, noted that Employee 1 was terminated for Resident mishandling which resulted in injury to the resident. The termination notice further noted that the incident strongly suggested that inappropriate handling and excessive use of force was used by Employee 1 and for that reason, Employee 1 was terminated.An interview with Resident was not possible. Resident 1 was discharged from the facility on 2/2/10, and now resides outside California. Additionally, an interview with the Director of Nursing (DON) employed by the facility at the time of the incident was not possible. The DON is now deceased as of January 2012. However, a written narrative dated 6/12/08, at 12:30 p.m., by the now deceased DON, indicated that Resident 1 was interviewed and stated: ?That person that we all don?t know well did this to my arm? Another written narrative indicated that the Resident had previously had been interviewed and told Evaluator 1 that ?The girl who hurt my arm took my ring.?On June 24, 2008, at 11:30 a.m., Evaluator 1 conducted an interview with Resident 1 regarding the missing ring and her injured left forearm.Evaluator 1 noted the following; ?On June 24, 2008, at 11:30 a.m. during an interview with Resident 1, the Director of Nursing (DON) initiated the conversation by reminding the resident about the day she lost her ring. The resident stated, ?She had her hand around my arm so tight that it hurt, and I could not sleep for days. She grabbed my arm and took the diamond ring from my finger.? When asked who grabbed her arm, the resident stated ?It was the one whose name she did not know.? The DON stated that was the first day Employee 1 was assigned to the resident.The Inventory List signed by Resident 1 the day she was admitted on March 10, 2005, showed she had three rings, including a platinum diamond wedding band ring. There was no documentation that the missing ring had been removed or signed out of the facility by the resident or responsible party.Evaluator 1 noted the following conversation during a second interview with the DON: In a telephone interview on August 26, 2008, at 11:45 a.m., the DON stated: ?That during the investigation on June 6, 2008, Employee 1 informed her that the resident was fighting and resisting as she tried to change her into a gown, and had to hold the arm to stop the resident from hitting her. The DON responded stated to Employee 1, ?I?ve never known in my year and a half in this facility, for her to be aggressive. This lady will resist only when she?s grabbed.? The DON further stated that ?Employee 1 must have seen an opportune time, placing the time of the incident when everyone was busy preparing the patients for lunch.? Evaluator 1 also conducted an interview with several staff. Evaluator 1 stated that ?In an interview on July 16, 2008, at 1:30 p.m., Employee 2 stated that Employee 1 called her to help assist in transferring Resident 1 from the commode to the wheelchair then left the resident with Employee 1. She stated she had never seen the resident being resistive to care, and the resident was very lucid that day. Employee 2 stated that about lunchtime, Employee 5 called her (Employee 2) to inquire about what had happened to the resident and then noticed the large bruise on the resident?s left arm. Evaluator 1 conducted an interview with Employee 3 on July 16, 2008. Evaluator 1 noted the following: ?In an interview on July 16, 2008, at 1:45 p.m., Employee 3 stated that the diamond ring was on Resident 1?s finger the day before the incident on June 6, 2008 and had never seen the resident being resistive to care.Evaluator 1 conducted an interview with Employee 4 on July 16, 2008. Evaluator 1 noted the following: ?In an interview on July 16, 2008, at 2 p.m., Employee 4 stated, ?On June 6, 2008, I noticed a bruise on the top of the resident?s left hand (forearm) that she tried to cover, then she said, ?The nurse was playing with my ring. I don?t know her name, but when I see her I will recognize who took the ring. She took my diamond. The ring does not mean anything to them, but it means so much to me?. Employee 4 stated that although Resident 1 has Alzheimer?s dementia she still went ahead and reported the resident?s allegations regarding her missing ring and her statements about Employee 1 to the administrator. Evaluator 1 conducted an interview with Employee 6 on July 16, 2008. Evaluator 1 noted the following: ?In a telephone interview on July 23, 2008, Employee 6 stated the resident never resisted care, and can remember faces, but cannot remember names. Employee 6 further stated that on June 6, 2008, shortly after she came to work at 3 p.m., she was called into the administrator?s office to ask about the ring. Employee 6 informed the administrator that the resident had the ring on her finger the evening before.The Police Department Crime Report dated June 24, 2008, indicated that Resident 1 did have periods of confusion when she was interviewed and did originally say that Employee 1 had entered the room for a ?Friendly visit.? She said she did not know how Employee 1 removed her ring from her finger. She then suddenly became upset and said that Employee 1 was a ?little thief? who knew what she wanted and stole it. Upon inspection of Resident 1?s left forearm, the crime report indicated that the detectives found that a portion of the originally raised bruise from June 6, 2008, was still present and was approximately the size of a half dollar and photographs were taken.A review of the facility?s policy and procedure titled ?Abuse Prevention? revealed that Abuse of an Elder or Dependent Adult includes physical abuse, or other treatment with resulting physical harm or pain or mental suffering. It further noted that the facility will take the following steps to prevent?allegations of abuse, and misappropriation of resident property by screening and ensuring that ?All CNAs will be properly screened for criminal background and approved by the Department of Health Services, through use of their CNA Abuse Registry and Certification Verification Program. It also noted that physical abuse included assaulting (hitting, slapping, pinching and kicking?or assault with a deadly weapon or force likely to produce great bodily injury. Misappropriation of Resident Property included the deliberate misplacement, exploitation or wrongful, temporary or permanent use of resident?s belongings or money without the resident?s consent. The facility failed to ensure that Resident A was free from physical abuse by Employee 1, who grabbed her arm forcefully and tightly, and stole her wedding ring off of her finger. As a result, Resident A complained of pain, sustained two large hematoma?s to the right forearm, and was transferred to the acute hospital emergency room for evaluation.The above violations had a direct relationship to the health, safety or security of Resident 1. |
| 970000066 |
THE CALIFORNIAN - PASADENA CONVALESCENT HOSPITAL |
950009267 |
B |
18-May-12 |
0B6111 |
13816 |
F226The facility must develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation and reporting of abuse, neglect, mistreatment and misappropriation of property.On February 28, 2012, at 3:15 p.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding an allegation of staff to resident abuse.Based on observation, interview, and record review, the facility failed to implement policies and procedures to protect Resident 1 from physical abuse and the theft of her ring by failing to: 1. Perform a criminal background check and to verify with the CNA Abuse Registry and Certification Program prior to hiring Employee 1, who had a long history of criminal activity in accordance to the facility?s abuse policy and procedure for screening. Consequently, Resident 1 was subjected to physical abuse by Employee 1, who grabbed her arm forcefully and tightly, and stole her wedding ring off of her finger. And as a result, Resident A complained of pain, sustained two large hematomas to the right forearm and received first aide treatment. On June 10, 2008, the Department received a faxed report from the facility that indicated that on 6/6/08, at 12:50 p.m., Resident 1 had sustained a hematoma (bruise) to her left forearm, while Employee 1 was trying to change her clothes. The report further indicated that Employee 1 stated that ?Resident 1 was fighting back and was trying to bite her.? A review of the admission and discharge Summary indicated that Resident 1 was a 98 year old female who was admitted to the facility on 3/10/05, with diagnoses that included senile dementia, degenerative joint disease, and osteoporosis. The Minimum Data Set (MDS- an assessment and care planning tool) dated February 25, 2008, indicated that the resident had short and long term memory problem, was severely impaired in cognitive skills for daily decision making and required limited assistance with one person physical assistance from staff for bed mobility, dressing, toileting use, personal hygiene, and bathing. The MDS further indicated that Resident 1 had no bruises or abrasions and exhibited no signs of physically abusive behavior or resistance to care. A review of the licensed nurse?s progress notes dated 6/6/08 at 12:50 p.m. indicated that Employee 4 reported to Employee 5, that there was a bruise on Resident 1?s left forearm. The bruise was described as two hematoma sites, which were raised and elevated, with a purple discoloration. The resident had a hematoma on the middle of her left forearm which measured 3 by 3 centimeters and another hematoma on the middle of her left forearm which measured 4 by 4 centimeters over 10 centimeters by 10 centimeters. Both hematomas were described as being raised and elevated with a purplish discoloration. A review of the facility?s Accident Investigation Report dated June 6, 2008, indicated that Resident 1 had sustained a hematoma to the left forearm. The hematoma was described as a large hematoma to the left arm, which spread to the entire forearm from the wrist to the elbow and had dark red bruising and a puncture mark on the outer aspect of the mid-forearm. The report quoted the resident as saying, ?That one, we don?t know too well did this to me?, and, ?Where is my engagement ring with the stone?? The facility?s interview indicated that Employee 1 had claimed that Resident 1 was fighting and biting while she was trying to change her pants. Employee 1 grabbed Resident 1?s arm to stop her. The report further indicated that Employee 1 was immediately suspended on 6/6/08, and subsequently terminated on 6/12/08. A review of Employee 1?s file revealed that she was hired by the facility on May 27, 2008, and had only worked for the facility for ten days. The employee file did not contain a verification of Employee 1?s CNA Certification and any documented evidence that a criminal background check was done prior to being hired.A review of the ?Progressive Discipline Verbal Counseling Verification? form dated 6/6/08 indicated that Employee 1 was verbally counseled regarding the incident and was told that Resident 1 had a bruise on her left forearm and that the facility residents were not to be held tightly. It further noted that when a resident is combative the nurse aide is to seek assistance from other staff to help in providing care for the resident.The Termination Notice for Employee 1 dated 6/12/08, noted that Employee 1 was terminated for Resident mishandling which resulted in injury to the resident. The termination notice further noted that the incident strongly suggested that inappropriate handling and excessive use of force was used by Employee 1 and for that reason, Employee 1 was terminated.An interview with Resident was not possible. Resident 1 was discharged from the facility on 2/2/10, and now resides outside California. Additionally, an interview with the Director of Nursing (DON) employed by the facility at the time of the incident was not possible. The DON is now deceased as of January 2012. However, a written narrative dated 6/12/08, at 12:30 p.m., by the now deceased DON, indicated that Resident 1 was interviewed and stated: ?That person that we all don?t know well did this to my arm.? Another written narrative indicated that the Resident had previously had been interviewed and told Evaluator 1 that ?The girl who hurt my arm took my ring.?On June 24, 2008, at 11:30 a.m., Evaluator 1 conducted an interview with Resident 1 regarding the missing ring and her injured left forearm. Evaluator 1 noted the following; ?On June 24, 2008, at 11:30 a.m. during an interview with Resident 1, the Director of Nursing (DON) initiated the conversation by reminding the resident about the day she lost her ring. The resident stated, ?She had her hand around my arm so tight that it hurt, and I could not sleep for days. She grabbed my arm and took the diamond ring from my finger.? When asked who grabbed her arm, the resident stated ?It was the one whose name she did not know.? The DON stated that was the first day Employee 1 was assigned to the resident. The DON showed the resident her diamond pendant for comparison to determine the weight of the diamond center stone; the resident stated the diamond on her ring was as big as the DON?s diamond pendant, or maybe bigger. The DON stated the diamond on her pendant is about three-quarters of a carat.The Inventory List signed by Resident 1 the day she was admitted on March 10, 2005, showed she had three rings, including a platinum diamond wedding band ring. There was no documentation that the missing ring had been removed or signed out of the facility by the resident or responsible party.Evaluator 1 noted the following conversation during a second interview with the DON: In a telephone interview on August 26, 2008, at 11:45 a.m., the DON stated: ?That during the investigation on June 6, 2008, Employee 1 informed her that the resident was fighting and resisting as she tried to change her into a gown, and had to hold the arm to stop the resident from hitting her. The DON responded stated to Employee 1, ?I?ve never known in my year and a half in this facility, for her to be aggressive. This lady will resist only when she?s grabbed.? The DON further stated that ?Employee 1 must have seen an opportune time, placing the time of the incident when everyone was busy preparing the patients for lunch.? Evaluator 1 also conducted an interview with several staff. Evaluator 1 stated that ?In an interview on July 16, 2008, at 1:30 p.m., Employee 2 stated that Employee 1 called her to help assist in transferring Resident 1 from the commode to the wheelchair then left the resident with Employee 1. She stated she had never seen the resident being resistive to care, and the resident was very lucid that day. Employee 2 stated that about lunchtime, Employee 5 called her (Employee 2) to inquire about what had happened to the resident and then noticed the large bruise on the resident?s left arm. Evaluator 1 conducted an interview with Employee 3 on July 16, 2008. Evaluator 1 noted the following: ?In an interview on July 16, 2008, at 1:45 p.m., Employee 3 stated that the diamond ring was on Resident 1?s finger the day before the incident on June 6, 2008. She also stated the resident would say to her, ?Look at this diamond. This is a present from my husband?. She stated she had never seen the resident being resistive to care.Evaluator 1 conducted an interview with Employee 4 on July 16, 2008. Evaluator 1 noted the following: ?In an interview on July 16, 2008, at 2 p.m., Employee 4 stated, ?On June 6, 2008, I noticed a bruise on the top of the resident?s left hand (forearm) that she tried to cover, then she said, ?The nurse was playing with my ring. I don?t know her name, but when I see her I will recognize who took the ring. She took my diamond. The ring does not mean anything to them, but it means so much to me?. Employee 4 stated that although Resident 1 has Alzheimer?s dementia she still went ahead and reported the resident?s allegations regarding her missing ring and her statements about Employee 1 to the administrator. Evaluator 1 conducted an interview with Employee 6 on July 16, 2008. Evaluator 1 noted the following: ?In a telephone interview on July 23, 2008, Employee 6 stated that on June 5, 2008, at 7 p.m., she saw the ring with the center stone on Resident 1?s finger as she prepared her for bed. She stated that the resident told her it was an engagement ring and she observed that the resident never took the ring off her finger, and that the resident knows her property. Employee 6 stated the resident never resisted care, and can remember faces, but cannot remember names. Employee 6 further stated that on June 6, 2008, shortly after she came to work at 3 p.m., she was called into the administrator?s office to ask about the ring. Employee 6 informed the administrator that the resident had the ring on her finger the evening before.Evaluator 1 conducted an interview with Employee 5 on July 16, 2008. Evaluator 1 noted the following: ?In a telephone interview on October 28, 2008, at 10:30 a.m., Employee 5 stated that on June 6, 2008, at 2 p.m., the administrator informed him that Employee 1 took the ring.However, the Police Department Crime Report dated June 24, 2012, indicated that the value of Resident 1?s ring was approximately $2000 in value and was described as a white gold ring with center diamond stone. The report also noted that Resident 1 did have periods of confusion when she was interviewed and did originally say that Employee 1 had entered the room for a ?Friendly visit.? She said she did not know how Employee 1 removed her ring from her finger. She then suddenly became upset and said that Employee 1 was a ?little thief? who knew what she wanted and stole it.Upon inspection of Resident 1?s left forearm, the crime report indicated that the detectives found that a portion of the originally raised bruise from June 6, 2008, was still present and was approximately the size of a half dollar and photographs were taken.A review of the Employment application completed and dated by Employee 1 on May 12, 2008, revealed that when the question ?Have you ever been convicted of a crime? was addressed on the employment application, Employee 1, indicated by checking the ?No? box that she had never been convicted of a crime. However, the Police Department?s Crime report indicated that the RAPS (Record of Arrest and Prosecution Sheet) revealed that Employee 1 had a long history of criminal activity dating back to 1986. Employee 1 was arrested for H/S 11350 (a), a possession of a controlled substance, PC 459, burglary, PC 242, battery, and PC 484 theft. It further indicated that Employee 1 was convicted of PC 484 and PC 242 in 1989.A review of the facility?s policy and procedure titled ?Abuse Prevention? revealed that Abuse of an Elder or Dependent Adult includes physical abuse, or other treatment with resulting physical harm or pain or mental suffering. It further noted that the facility will take the following steps to prevent?allegations of abuse, and misappropriation of resident property by screening and ensuring that ?All CNAs will be properly screened for criminal background and approved by the Department of Health Services, through use of their CNA Abuse Registry and Certification Verification Program. It also noted that physical abuse included assaulting (hitting, slapping, pinching and kicking?or assault with a deadly weapon or force likely to produce great bodily injury. Misappropriation of Resident Property included the deliberate misplacement, exploitation or wrongful, temporary or permanent use of resident?s belongings or money without the resident?s consent. The facility failed to implement policies and procedures to protect Resident 1 from physical abuse and the theft of her ring by failing to: 1. Perform a criminal background check and to verify with the CNA Abuse Registry and Certification Program prior to hiring Employee 1, who had a long history of criminal activity in accordance to the facility?s abuse policy and procedure for screening. Consequently, Resident A was subjected to physical abuse by Employee 1, who grabbed her arm forcefully and tightly, and stole her wedding ring off of her finger. And as a result, Resident A complained of pain, sustained two large hematomas to the right forearm and received first aide treatment. The above violations had a direct relationship to the health, safety or security of Resident 1. |
| 970000066 |
THE CALIFORNIAN - PASADENA CONVALESCENT HOSPITAL |
950009317 |
B |
18-May-12 |
0B6111 |
11981 |
F224483.13 (c) The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. On February 28, 2012, at 3:15 p.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding an allegation of staff to resident abuse.Based on observation, interview, and record review, the facility failed to ensure that Resident A was free from misappropriation of Resident Property by failing to: 1. Ensure that Employee 1 did not misappropriate Resident 1?s wedding ring off of her finger, by forcefully stealing and removing her wedding ring which meant a lot to her. Subsequently, Resident 1 sustained two hematomas on her left forearm which required first aide treatment.On June 10, 2008, the Department received a faxed report from the facility that indicated that on 6/6/08, at 12:50 p.m., Resident 1 had sustained a hematoma (bruise) to her left forearm, while Employee 1 was trying to change her clothes. The report further indicated that Employee 1 stated that ?Resident 1 was fighting back and was trying to bite her.? A review of the admission and discharge Summary indicated that Resident 1 was a 98 year old female who was admitted to the facility on 3/10/05, with diagnoses that included senile dementia, degenerative joint disease, and osteoporosis. The Minimum Data Set (MDS- an assessment and care planning tool) dated February 25, 2008, indicated that the resident had short and long term memory problem, was severely impaired in cognitive skills for daily decision making and required limited assistance with one person physical assistance from staff for bed mobility, dressing, toileting use, personal hygiene, and bathing. The MDS further indicated that Resident 1 had no bruises or abrasions and exhibited no signs of physically abusive behavior or resistance to care. A review of the licensed nurse?s progress notes dated 6/6/08 at 12:50 p.m. indicated that Employee 4 reported to Employee 5, that there was a bruise on Resident 1?s left forearm. The bruise was described as two hematoma sites, which were raised and elevated, with a purple discoloration. The resident had a hematoma on the middle of her left forearm which measured 3 by 3 centimeters and another hematoma on the middle of her left forearm which measured 4 by 4 centimeters over 10 centimeters by 10 centimeters. Both hematomas were described as being raised and elevated with a purplish discoloration. A review of the facility?s Accident Investigation Report dated June 6, 2008, indicated that Resident 1 had sustained a hematoma to the left forearm. The hematoma was described as a large hematoma to the left arm, which spread to the entire forearm from the wrist to the elbow and had dark red bruising and a puncture mark on the outer aspect of the mid-forearm. The report quoted the resident as saying, ?That one, we don?t know too well did this to me?, and, ?Where is my engagement ring with the stone?? The facility?s interview indicated that Employee 1 had claimed that Resident 1 was fighting and biting while she was trying to change her pants. Employee 1 grabbed Resident 1?s arm to stop her. The report further indicated that Employee 1 was immediately suspended on 6/6/08, and subsequently terminated on 6/12/08. A review of Employee 1?s file revealed that she was hired by the facility on May 27, 2008, and had only worked for the facility for ten days.The Termination Notice for Employee 1 dated 6/12/08, noted that Employee 1 was terminated for Resident mishandling which resulted in injury to the resident. The termination notice further noted that the incident strongly suggested that inappropriate handling and excessive use of force was used by Employee 1 and for that reason, Employee 1 was terminated.An interview with Resident 1 was not possible. Resident 1 was discharged from the facility on 2/2/10, and now resides outside California. Additionally, an interview with the Director of Nursing (DON) employed by the facility at the time of the incident was not possible. The DON is now deceased as of January 2012. However, a written narrative dated 6/12/08, at 12:30 p.m., by the now deceased DON, indicated that Resident 1 was interviewed and stated: ?That person that we all don?t know well did this to my arm? Another written narrative indicated that the Resident had previously had been interviewed and told Evaluator 1 that ?The girl who hurt my arm took my ring.?On June 24, 2008, at 11:30 a.m., Evaluator 1 conducted an interview with Resident 1 regarding the missing ring and her injured left forearm.Evaluator 1 noted the following; ?On June 24, 2008, at 11:30 a.m. during an interview with Resident 1, the Director of Nursing (DON) initiated the conversation by reminding the resident about the day she lost her ring. The resident stated, ?She had her hand around my arm so tight that it hurt, and I could not sleep for days. She grabbed my arm and took the diamond ring from my finger.? When asked who grabbed her arm, the resident stated ?It was the one whose name she did not know.? The DON stated that was the first day Employee 1 was assigned to the resident. The DON showed the resident her diamond pendant for comparison to determine the weight of the diamond center stone; the resident stated the diamond on her ring was as big as the DON?s diamond pendant, or maybe bigger. The DON stated the diamond on her pendant is about three-quarters of a carat.The Inventory List signed by Resident 1 the day she was admitted on March 10, 2005, showed she had three rings, including a platinum diamond wedding band ring. There was no documentation that the missing ring had been removed or signed out of the facility by the resident or responsible party.Evaluator 1 noted the following conversation during a second interview with the DON: In a telephone interview on August 26, 2008, at 11:45 a.m., the DON stated: ?That during the investigation on June 6, 2008, Employee 1 informed her that the resident was fighting and resisting as she tried to change her into a gown, and had to hold the arm to stop the resident from hitting her. The DON responded stated to Employee 1, ?I?ve never known in my year and a half in this facility, for her to be aggressive. This lady will resist only when she?s grabbed.? The DON further stated that ?Employee 1 must have seen an opportune time, placing the time of the incident when everyone was busy preparing the patients for lunch.? Evaluator 1 also conducted an interview with several staff. Evaluator 1 stated that ?In an interview on July 16, 2008, at 1:30 p.m., Employee 2 stated that Employee 1 called her to help assist in transferring Resident 1 from the commode to the wheelchair then left the resident with Employee 1. She stated she had never seen the resident being resistive to care, and the resident was very lucid that day. Employee 2 stated that about lunchtime, Employee 5 called her (Employee 2) to inquire about what had happened to the resident and then noticed the large bruise on the resident?s left arm. Evaluator 1 conducted an interview with Employee 3 on July 16, 2008. Evaluator 1 noted the following: ?In an interview on July 16, 2008, at 1:45 p.m., Employee 3 stated that the diamond ring was on Resident 1?s finger the day before the incident on June 6, 2008. She also stated the resident would say to her, ?Look at this diamond. This is a present from my husband?. She stated she had never seen the resident being resistive to care.Evaluator 1 conducted an interview with Employee 4 on July 16, 2008. Evaluator 1 noted the following: ?In an interview on July 16, 2008, at 2 p.m., Employee 4 stated, ?On June 6, 2008, I noticed a bruise on the top of the resident?s left hand (forearm) that she tried to cover, then she said, ?The nurse was playing with my ring. I don?t know her name, but when I see her I will recognize who took the ring. She took my diamond. The ring does not mean anything to them, but it means so much to me?. Employee 4 stated that although Resident 1 has Alzheimer?s dementia she still went ahead and reported the resident?s allegations regarding her missing ring and her statements about Employee 1 to the administrator. Evaluator 1 conducted an interview with Employee 6 on July 16, 2008. Evaluator 1 noted the following: ?In a telephone interview on July 23, 2008, Employee 6 stated that on June 5, 2008, at 7 p.m., she saw the ring with the center stone on Resident 1?s finger as she prepared her for bed. She stated that the resident told her it was an engagement ring and she observed that the resident never took the ring off her finger, and that the resident knows her property. Employee 6 stated the resident never resisted care, and can remember faces, but cannot remember names. Employee 6 further stated that on June 6, 2008, shortly after she came to work at 3 p.m., she was called into the administrator?s office to ask about the ring. Employee 6 informed the administrator that the resident had the ring on her finger the evening before.Evaluator 1 conducted an interview with Employee 5 on July 16, 2008. Evaluator 1 noted the following: ?In a telephone interview on October 28, 2008, at 10:30 a.m., Employee 5 stated that on June 6, 2008, at 2 p.m., the administrator informed him that Employee 1 took the ring.However, the Police Department Crime Report dated June 24, 2012, indicated that the value of Resident 1?s ring was approximately $2000 in value and was described as a white gold ring with center diamond stone. The report also noted that Resident 1 did have periods of confusion when she was interviewed and did originally say that Employee 1 had entered the room for a ?Friendly visit.? She said she did not know how Employee 1 removed her ring from her finger. She then suddenly became upset and said that Employee 1 was a ?little thief? who knew what she wanted and stole it.Upon inspection of Resident 1?s left forearm, the crime report indicated that the detectives found that a portion of the originally raised bruise from June 6, 2008, was still present and was approximately the size of a half dollar and photographs were taken.A review of the Employment application completed and dated by Employee 1 on May 12, 2008, revealed that when the question ?Have you ever been convicted of a crime? was addressed on the employment application, Employee 1, indicated by checking the ?No? box that she had never been convicted of a crime. However, the Police Department?s Crime report indicated that the RAPS (Record of Arrest and Prosecution Sheet) revealed that Employee 1 had a long history of criminal activity dating back to 1986. Employee 1 was arrested for H/S 11350 (a), a possession of a controlled substance, PC 459, burglary, PC 242, battery, and PC 484 theft. It further indicated that Employee 1 was convicted of PC 484 and PC 242 in 1989.A review of the facility?s policy and procedure titled ?Abuse Prevention? revealed that Abuse of an Elder or Dependent Adult indicates that Misappropriation of Resident Property is the deliberate misplacement, exploitation or wrongful, temporary or permanent use of resident?s belongings or money without the resident?s consent. Based on observation, interview, and record review, the facility failed to ensure that Resident A was free from misappropriation of Resident Property by failing to: 1. Ensure that Employee 1 did not misappropriate Resident 1?s wedding ring off of her finger, by forcefully stealing and removing her wedding ring which meant a lot to the resident. Subsequently, Resident 1 sustained two hematomas on her left forearm which required first aide treatment.The above violations had a direct relationship to the health, safety or security of Resident 1. |
| 950000013 |
THE ROWLAND |
950009333 |
B |
24-May-12 |
1BSL11 |
5547 |
F 206 483.12 (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 2/7/12 at 2:45 p.m., an unannounced visit was made to the skilled nursing facility (SNF) to investigate a complaint regarding an incident of alleged refusal to readmit Resident A. Based on interview and record review, the facility failed to ensure that Resident A, who was eligible for Medicaid benefits was re-admitted to the Skilled Nursing Facility when her hospitalization had exceeded the bed-hold period under the State?s plan, by failing to:Offer Resident A, who was Medical-eligible and had a pending Medi-Cal benefit, the next available bed appropriate for the resident?s needs. As a result of the SNF refusal to readmit Resident A, the resident remained in the acute care hospital for 14 additional days from 1/25/12, through 2/7/12 days after the resident?s condition had been deemed stable by the physician and the physician had ordered the resident?s discharged and transferred back to the SNF.Resident A, a 62 year-old female was readmitted to the SNF on 1/6/12, with diagnoses of chronic hypokalemia (low potassium), depression, chronic back pain, lower gastrointestinal bleeding and hypertension. The Notice of Action from the Medi-Cal (Medicaid) Office, dated July 13, 2011, indicated that the resident?s Medi-cal benefits were in the pending status and that Resident A?s was eligible to receive full Medi-Cal benefits as of July 1, 2011, according to the Medi-Cal (Medicaid) Office Notice of Action dated March 30, 2012.A review of the licensed nurses? notes dated 1/7/12 revealed that Resident A was transferred from the SNF to the acute care hospital for treatment due to abdominal distention.A review of the medical record from the acute care hospital revealed that on 1/25/12, (more than 7 days later), Resident A?s health condition was stable and the physician ordered the resident be transferred back to the SNF. On 1/25/12, the acute care hospital resident care coordinator notified SNF?s Employee 1 that the resident was ready to be discharged to the SNF but Employee 1 refused to readmit Resident A. According to the acute care hospital social service progress notes dated 2/6/12, Resident A stated that the SNF is her home and she would like to return there. A review of Resident A?s transfer record in the SNF on 2/7/12, revealed that upon Resident A?s transfer to the acute hospital on 1/7/12, the written bed hold notice was not given to Resident A and /or to the resident?s representative.During an interview with SNF Employee 2 on 2/7/12 at 4:00 p.m., she stated the licensed staff forgot to provide a written bed hold notice to Resident A and /or to the resident?s representative upon Resident A?s transfer to the acute hospital on 1/7/12. Employee 2 further disclosed that there were available beds on 1/25/12, but Employee 3 told her not to readmit Resident A because the Resident had exceeded the seven day bed hold and that the Resident was non-compliant with care.During an interview with Employee 3 on 2/8/12 at 10:50 a.m., he confirmed that he told Employee 2 via phone on 2/7/12, not to readmit Resident A because the resident had exceeded the seven day bed hold and that the resident was non-compliant with care. However, a review of the SNF?s written Bed Holds and Readmission policy dated February 2005, indicated, ?If you are eligible for Medi-Cal, if you are away from our Facility for more than seven days due to hospitalization or other medical treatment, we will readmit you to the next available appropriate bed room if you need the care provided by our Facility and wish to be readmitted?. There was no evidence that the SNF readmitted Resident A, in accordance with the readmission policy. Additionally, a review of the SNF?s undated transfer/discharge policy revealed that ?upon a patient?s transfer to the acute hospital, the facility must provide a written bed hold notice to the resident and /or the resident?s representative.? There was no evidence that the SNF provided a written bed hold notice to the resident and /or to the resident?s representative in accordance with the facility?s policy. On 1/25/12, after the acute care hospital physician ordered the resident to be discharged to the SNF, Resident A remained in the acute hospital for 14 additional days from 1/25/12, through 2/7/12. Resident A was readmitted to SNF on 2/8/12 at 3:10 p.m., after the Evaluator had issued intent to cite the SNF on 2/8/12, due to refusal to readmit Resident A.The facility failed to follow the facility readmission policy by failing to:Offer Resident A, who was Medical-eligible and had a pending Medi-Cal benefits, the next available bed appropriate for the resident?s needs. As a result of the SNF refusal to readmit Resident A, the resident remained in the acute care hospital for 14 additional days from 1/25/12, through 2/7/12 days after the resident?s condition had been deemed stable by the physician and the physician had ordered the resident?s discharged and transferred back to the SNF.These violations had a direct and immediate relationship to the health, safety and security of Resident A. |
| 950000013 |
THE ROWLAND |
950009483 |
B |
11-Sep-12 |
JMK511 |
7776 |
The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. On February 22, 2011, through March 4, 2011, during a re-certification and re-licensure survey, an investigation was conducted as a result of complaints made by the residents regarding social services.The facility failed to ensure that the residents? social service needs were met by failing to:1. Provide an appropriate wheelchair to support proper body alignment of a resident (Resident 15). 2. Provide necessary dental care for a resident (Resident 21).This resulted in Resident 15 using a wheelchair that did not support her head and neck for over 5 months, causing the resident discomfort and a delay in receiving appropriate dental services for Resident 21.1. A review of the admission information record on February 25, 2011, indicated that Resident 15 was admitted to the facility on September 17, 2010. The resident's diagnoses included, cervical disco genic disease (it is a gradual deterioration of the intervertebral discs in the spine, a process that is a natural part of aging), cerebrovascular accident (CVA- stroke), and chronic pain syndrome. The most recent Minimum Data Set MDS- (a standardized comprehensive assessment and care planning tool) dated January 6, 2011, indicated that the resident was assessed as having no cognitive and decision making skills and was able to verbalize needs. Resident 15 required minimal to extensive assistance in carrying out activities of daily living. The resident relied on the use of a wheelchair for ambulation and locomotion.During the survey on February 25, 2011 at 3:30 p.m., the resident was observed, independently propelling a wheelchair with her neck hyper-extended and her head hanging backwards without an assistive device or support.On February 25, 2011, at 3:50 p.m. the RN (registered nurse) Supervisor 1 was interviewed. RN Supervisor 1 stated that Resident 15 had chronic neck and back pain due to a laminectomy procedure [(surgical removal of the bony arches of one or more vertebrae (a bone of the spinal column)].RN Supervisor 1 stated that the resident was offered a facility high back wheelchair to support her head and neck but many times the resident had refused for an unspecified reason.During an interview with Resident 15 on March 1, 2011 at 3:30 p.m., she stated that she refused the high back wheelchair that was provided to her by the facility because it was uncomfortable and it made her neck and back pains worse. The resident stated she wanted her old power wheelchair which was still at home because the wheelchair had an adjustable head/neck support to make her feel comfortable. The resident however, stated that the power wheelchair was broken, and her mother had notified the facility staff of the condition of the wheelchair that was now at home.During an interview with the social service designee (SSD) 1 on March 3, 2011, at 10 a.m., she stated that Resident 15?s mother had no means to transport the resident's wheelchair from home to the facility, and the resident's old wheelchair at home was broken and inoperable. SSD 1 further stated that she would verify if the resident's insurance would cover the expense of a new wheelchair to make the resident feel comfortable. Review of the resident?s social service progress notes from November 2010, to February 2011, did not contain any documented evidence that the social worker assessed Resident 15 so as to determine the reason for her refusal to use a high back wheelchair that the facility offered to the resident and inquire about Resident 15?s broken and inoperable wheelchair. Furthermore, there was no documented evidence that the social services staff provided any interventions / involvement in assisting the resident and/or the resident's family in obtaining a wheelchair that would have provided the most comfort for Resident 15, until after the evaluator intervened.2. During an observation on February 24, 2011 at 8:10 a.m., Resident 21 was observed sitting in a wheelchair eating breakfast in front of an over bed table. During this observation, the resident stated "I need dentures; I have a hard time eating." The resident also stated he had been seen by a private dentist. A review of the admission information record, indicated Resident 21 was admitted to the facility on October 2, 2010, with diagnoses that included renal failure (failure of the kidneys to function properly) gastro-esophageal reflex disorder (GERD- acid reflux or heartburn). The psychosocial evaluation form dated October 2, 2010, indicated that the resident had his own teeth.The most recent quarterly MDS dated January 15, 2011, indicated that Resident 21 was assessed as requiring extensive to total assistance from staff for the performance of activities of daily living (ADL) and had the ability to recall and repeat the words. On February 24, 2011, a review of the dental notes dated December 16, 2010, indicated that the resident had an initial oral examination by a dentist who recommended a full mouth x-ray (FMX) for the resident.There was no documentation in the dental notes or on the social service notes subsequent to December 16, 2010, to indicate that the x-ray (FMX) was acknowledged or action taken as recommended by the dentist. There was no documented evidence that social services had conducted a follow-up to ensure that the recommended dental x-rays were done until after the evaluator intervened. On February 24, 2011 at 11:05 a.m., during an interview with social service designee (SSD) 2, she acknowledged that she should have followed up the December 16, 2010 recommendation for a full mouth x-ray (FMX) with Resident 21's responsible party and should not have waited until after the resident had expressed his need for dentures to the evaluator. The facility's undated policy and procedure titled "Social Services Dental Consultation Protocol," indicated that the dental office will notify the social services department to routinely follow up every two weeks with the dentist while the dentist awaits the resident?s insurance approval and authorization to initiate the dental procedure. This protocol was not implemented because the social service designee (SSD) 2 did not follow through with the dentist?s recommendation for a full mouth x-ray (FMX) for Resident 21.A review of the undated "Social Services Job Description" indicated, ?The designated staff responsible to provide the needs of the residents regarding social services consists of a social worker. The essential requirements and functions included, sufficient time to perform social services functions and assumes the responsibility for making plans to meet the initial and ongoing psychological needs of residents and families."The facility?s failure to provide Resident 15 a wheelchair that supported her head and neck for over 5 months, and failure to provide necessary dental care for Resident 21 resulted in unmet social service needs for Resident 15 and Resident 21.The facility failed to ensure the resident?s social service needs were met by failing to:1. Provide an appropriate wheelchair to support proper body alignment of a resident (Resident 15). 2. Provide necessary dental care for a resident (Resident 21). This resulted in Resident 15 using a wheelchair that did not support her head and neck for over 5 months, causing the resident discomfort and a delay in receiving appropriate dental services for Resident 21.These violations had a direct relationship to the health, safety or security of Resident 15 and Resident 21 and all of the residents in the facility. |
| 970000176 |
TWO PALMS NURSING CENTER, INC. |
950009852 |
B |
22-Apr-13 |
UD4Y11 |
6849 |
F221-The resident has the right to be free from any physical restraint imposed for purposes of discipline or convenience, and not required to treat the resident?s medical symptoms. On 1/22/2013, an unannounced annual Recertification survey was made to the facility.Based on observation, interview and record review the facility failed to: 1. Ensure a resident had a specific medical symptom before the use of a physical restraint. 2. Attempt a less restrictive device for a resident before the use of a restrictive physical device. 3. Develop a care plan to fully address the monitoring needs of a resident who used a physically restrictive device. 4. Discontinue the use of a restrictive physical restraint for a resident when the resident had contraindications for the use of the restraint, such as sliding from the wheelchair and having a fall risk.The use of a restrictive physical device not required to treat the resident's medical symptoms, and when the resident had contraindications for the use of the restraint, had the potential to result in accidental chest compression and suffocation.A review of the admission information indicated that Resident 4 was admitted to the facility on 9/13/11, with diagnoses that included seizure disorder, schizophrenia (chronic brain disorder interfering with a person?s ability to think clearly, manage emotions, makes decisions and relate to others) and diabetes mellitus (high blood sugar). The resident was assessed with short and long term memory recall problems and required extensive assistance in ambulation according to the Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 12/26/12.The care plan interventions titled "Physical Restraint" dated 9/26/2012, indicated the nursing staff were to: Monitor for less restrictive measures and to provide frequent visual checks of the resident. The care plan did not address how to, or when to provide monitoring and visual checks relating to the use of the physical restraint.On 1/23/13 at 10 a.m., the resident was observed quiet and seated upright in a wheelchair while in the activity room. The resident had a non-self-release waist belt tied to the back of his wheelchair. The resident demonstrated that he could not remove the non-self-release waist belt by trying to his put his hands behind his back where it was tied. The resident did not answer when asked why he had a non-self-release waist belt. A review of Resident's 4 medical record with Staff 1 on 1/25/13 at 10:50 a.m., revealed that a lap belt was ordered by the physician on 6/27/12, to be applied when Resident 4 was sitting in a wheelchair for safety and body alignment due to poor safety judgment and constant sliding down from the wheelchair. Staff 1 stated that the non-self-release waist belt was the same device referred to as a lap belt. Staff 1 disclosed that the resident had fallen from the wheelchair (on an unspecified date) while wearing a lap belt.According to the licensed nurses' notes dated 11/6/12 at 10 p.m., the resident was witnessed by the licensed nurse and a certified nursing assistant (CNA) to have slid down from the wheelchair and was found with half of his body on the floor while wearing a lap belt. The resident did not sustain an injury.On 1/25/13 at 10:50 a.m., further interview with Staff 1 revealed that the use of a lap belt for Resident 4 was not discontinued after the fall incident on 11/6/12. When asked why the lap belt was needed by the resident, Staff 1 stated, "He slides down from wheelchair." Staff 1 disclosed that the interdisciplinary team notes dated 11/13/12, indicated that the continued use of a lap belt for Resident 4 was recommended due to constant sliding down from wheelchair. According to Staff 1, he called the physician on 11/13/12, for an order for the continuous use of a lap belt for Resident 4, because the lap belt was safe for the resident as a method to prevent sliding down and falls from the wheelchair. The physician's order sheet dated 11/13/12, revealed there was an order to apply a lap belt when the resident was sitting in a wheelchair for safety and body alignment due to constant sliding down related to poor safety judgment. Staff 1 further disclosed that the resident still fell from the wheelchair after the use of a lap belt was reordered by the physician on 11/13/12. The licensed nurses' notes dated 12/8/12 at 5:47 p.m., revealed that staff heard a yell from the dining room and that the resident was found leaning over to the left side while sitting on the floor. The resident sustained an abrasion of the left knee and complained of pain of the left hip. (No fractures were revealed through the X-ray dated 12/8/12.) Staff 1 stated that less restrictive measures were tried before the use of a lap belt for Resident 4. However, Staff 1 was unable to provide documented evidence that consisted of specific dates and time of when other appropriate, less restrictive measures for positioning/physical support were attempted, before the use of a lap belt for Resident 4. Additionally, although the resident was not observed by the surveyor to slide down from the wheelchair, there was no documented evidence that Resident 4 was referred to a physical therapist (PT), or other appropriate professional discipline for determining the need for positioning devices or assessed by the PT as having a postural problem that required the use of a lap belt. There was no documented evidence that the resident had a specific medical symptom to justify the continued use of the non-self-release lap belt.A review of the application instruction sheet for a lap belt/padded lap belt device titled "Contraindications" indicated "Discontinue use immediately if the patient is able to slide forward or down underneath the device. They could slide far enough under the device to become suspended, resulting in chest compression and suffocation."The facility failed to: 1. Ensure a resident had a specific medical symptom before the use of a physical restraint. 2. Attempt a less restrictive device for a resident before the use of a restrictive physical device. 3. Develop a care plan to fully address the monitoring needs of a resident who used a physically restrictive device. 4. Discontinue the use of a restrictive physical restraint for a resident when the resident had contraindications for the use of the restraint, such as sliding from the wheelchair and having a fall risk.The use of a restrictive physical device not required to treat the resident's medical symptoms, and when the resident had contraindications for the use of the restraint, had the potential to result in accidental chest compression and suffocation. The above violations had a direct relationship to the health, safety and security of Resident 4. |
| 950000013 |
THE ROWLAND |
950010603 |
B |
08-Apr-14 |
GGNJ11 |
2185 |
Health & Safety Code 1418.21(a)(I)(A)-A skilled nursing facility that has been certified for purpose of Medicare or Medicaid shall post the overall facility rating information determined by the federal Center of Medicare and Medicaid Services in accordance with the following requirements:(l) 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.Between September 26, 2013, and September 28, 2013, a recertification visit was made to the facility.Based on observation and interview, the facility failed to comply with the State regulation by failing to post the overall facility rating information at an area accessible to members of the public.Findings: On September 26, 2013, between 5:50 p.m. and 7:25 p.m., during the initial tour of the facility, the evaluator observed the facility?s overall rating information was not posted at the lobby, nursing stations, dining/activity room, social service office, or employee lounge.On September 27, 2013, between 9:15 a.m., and 9:55 a.m., during second tour of the facility, the evaluator observed the facility's overall rating information was not posted.On September 28, 2013, between 7:45a.m., and 8:15 a.m., during a third tour of the facility, the evaluator observed the facility?s overall rating information was still not posted. On September 28, 2013, at 10:30 a.m., the evaluator conducted an interview with Staff 1 regarding the facility?s overall rating information. Staff 1 was asked why the facility?s overall rating information was not posted on a daily basis at the areas, accessible to residents, staff and visitors. Staff 1 stated that he was not aware that the overall rating information had to be posted, per State regulation. Staff 1 added that this would be corrected, immediately. The facility failed to comply with the State regulation by failing to: Post the overall facility rating information at an area accessible to members of the public. Failure of the facility to post the overall rating information constitutes a Citation B violation, as defined in Subdivision (a)(I)(A), Section 1418.21. |
| 950000013 |
THE ROWLAND |
950012569 |
A |
14-Sep-16 |
F2K311 |
11767 |
F 314 483.2 (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. Based on observation, interview and record review the facility failed to prevent the development and progression of avoidable pressure sore (localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and /or friction) for Resident A who was at risk for developing pressure sore by failing to: 1. Revise the plan of care to address the frequency in which the resident should be turned, as well as positioning the resident while in bed. 2. Ensure the resident was not lying on his back directly on the pressure sore. 3. Accurately assess the skin condition of sacrum (a triangular shaped bone at the bottom of the spine) pressure sore. 4. Monitor and report skin changes to the physician. These failures resulted in Resident A developing an avoidable stage III pressure sore (full thickness tissue loss, subcutaneous [under the skin] fat may be visible but bone, tendon or muscle are not exposed) to his sacrum. A review of the admission assessment dated 4/3/15, indicated Resident A was readmitted to the facility without a pressure sore. Resident A diagnoses included Parkinson's disease (a disease of the nervous system that mostly affects older people) and dementia (a brain condition that causes problem with thinking and memory). A review of the Minimum Data Set (MDS-a standardized assessment and care planning tool) dated 2/24/16, indicated Resident A was assessed with short and long term memory recall problems, totally dependent in bed mobility (full staff performance every time during entire seven day period) and was incontinent (lack of voluntary control over urination or defecation) of bowel and bladder. A review of the Braden Scale Assessment (a nursing tool which uses a scoring system to evaluate resident's risk of developing a pressure sore) dated 2/29/16, indicated Resident A scored 13 which indicated Resident A was at moderate risk of developing pressure sore. On 3/17/16 at 8:20 a.m., the medical record of Resident A was reviewed with the Director of Nursing (DON) and Treatment Nurse 2. The "Skin Condition/Wound progression" notes of Treatment Nurse 1 dated 11/3/15 indicated she assessed Resident A with redness (stage 1 pressure ulcer- intact skin with non-blanchable redness of a localized area usually over a bony prominence) on his sacrum. On 11/5/15, Treatment Nurse 1 assessed Resident A's sacrum as stage II pressure sore with minimal yellow colored drainage. The pressure sore measured 4 centimeter (cm) in length (L) by (x) 3 cm in width (W) and 0.1 cm in depth (2.5 cm = 1 inch). The physician was made aware of this information on 11/5/15; Resident A had a stage II pressure sore to his sacrum. The treatment order dated 11/05/2015, indicated to cleanse the sacral stage II pressure sore with normal saline (salt water solution) pat dry, apply Collagen (use to heal moist wound), apply Hydrogel (help regulate fluid exchange from the wound surface ) and cover the pressure sore with dry dressing every day. Treatment Nurse 1?s notes dated 11/20/15 through 1/29/16 indicated she continued to assess and categorize the resident's sacrum pressure sore as stage II despite the pressure sore drainage which was yellow and tan in color. According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure ulcer with full thickness tissue loss, visible subcutaneous fat with no bone, tendon or muscle exposure, with slough (yellow, tan, gray, green or brown) that does not obscure the depth of tissue loss is a stage 3 pressure ulcer. The Physician Progress Notes dated 1/31/16 indicated the physician assessed the resident's sacrum as stage III pressure sore and no new treatment for the pressure sore was ordered. Although the physician had assessed Resident A's sacrum as stage III pressure sore on 1/31/16, Treatment Nurse 1 and Licensed Vocational Nurse (LVN 4) notes dated 2/2/16 through 3/11/16, indicated they both continued to assess and categorize the pressure sore as stage II with yellow and tan colored drainage. On 3/14/16, Treatment Nurse 2 assessed Resident A's sacrum as stage III pressure sore measuring 1 cm in length x 0.5 in width with 0.3 cm in depth. On 3/17/16 at 8:20 a.m., Resident A's Care Plan was reviewed with the DON and Treatment Nurse 2. The resident?s initial Care Plan dated 4/7/15 indicated Resident A was assessed at risk for skin breakdown due to decreased bed mobility. The Care Plan goal was for Resident A not to have a skin breakdown by the next review on 5/31/16. The Care Plan dated 3/11/16, indicated the resident developed a stage II pressure sore (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough [dead tissue] and may present as an intact or open/ruptured blister) to his sacrum. The Care Plans dated 4/7/15 and 3/11/16, indicated turning and repositioning the resident while in bed. However, both Care Plans did not indicate the frequency and which specific side the resident's body should be turned and repositioned to prevent pressure sore development and to prevent worsening of the existing pressure sore. The Care Plan dated 3/14/16, indicated the resident's stage II pressure sore to his sacrum had progressed to stage III pressure sore. The Care Plan for sacrum stage III pressure sore dated 3/14/16, did not indicate turning and repositioning Resident A while in bed and the care approaches were not revised to promote healing of the pressure sore and to prevent further skin breakdown. According to Medical Surgical Nursing Ninth Edition pages 186-187, "Prevention remains the best treatment for pressure sores. Reposition the patients frequently to prevent pressure sore at least every two hours and every hour when in chair. Never position the patient directly on the pressure sore." On 3/15/16 at 7:35 a.m., an initial tour of the facility was conducted with Registered Nurse (RN 1). Resident A was observed lying on his back on a low air loss mattress (a mattress that provides a flow of air to assist in managing the heat and humidity of the skin). Resident A had involuntary movements to both arms and his hands were contracted. The resident was non-communicative. Further observations on 3/15/16 at 9:35 a.m., 10:37 a.m., 11:30 a.m., 1:20 p.m., 2:40 p.m., 3:38 p.m., and 4:13 p.m., Resident A was observed lying on his back in bed. On 3/16/16, the resident was observed lying on his back while in bed at 7:14 a.m., 9:09 a.m., 9:50 a.m., 10:02 a.m., and 1:40 p.m. During the treatment observation on 3/16/16 at 10:02 a.m., Resident A was observed with stage III pressure sore to his sacrum. Treatment Nurse 2 measured the pressure sore as 1.4 cm in length x 1 cm in width with 0.3 cm in depth. The wound bed had a moderate amount of yellow colored slough (dead tissue). Treatment Nurse 2 cleansed the sacrum pressure sore with normal saline, applied Collagen powder, applied Hydrogel gauze and covered the pressure sore with a dry dressing. During an interview on 3/16/16 at 2:50 p.m., Certified Nursing Assistant (CNA 1) stated LVN 4 (licensed vocational nurse) informed CNA 1 that Resident A had stage III pressure sore to his sacrum. CNA 1 stated the facility had "Patient Repositioning Schedule." The written copy of the "Patient Repositioning Schedule" was placed on the back of CNA 1?s identification card. The "Patient Repositioning Schedule" indicated to reposition the resident every two hours as follows: 7:00 a.m. - 9:00 a.m. - Back 9:00 p.m. - 11:00 p.m. - Right side 9:00 a.m. - 11:00 a.m. - Right side 11:00 p.m. - 1:00 a.m. - Back 11:00 a.m. - 1:00 p.m. - Back 1:00 a.m. - 3:00 a.m. - Left side 1:00 p.m. - 3:00 p.m. - Left side 3:00 a.m. - 5:00 a.m. - Right side 3:00 p.m. - 5:00 p.m. - Right side 5:00 a.m. - 7:00 a.m. - Left side 5:00 p.m.-7:00 p.m.- Back 7:00 p.m. - 9:00 p.m. - Left side CNA 1 stated he was unable to turn and reposition Resident A every two hours because he was busy taking care of another resident. CNA 1 stated he turned and repositioned the resident to his right side, left side and back when in bed. CNA 1 was not informed by staff member that Resident A should not be turned and repositioned on his back while in bed. CNA 1 stated when the resident is lying on the site of pressure sore it will get worse due to pressure. During an interview on 3/17/16 at 9:18 a.m., DON and Treatment Nurse 2 both stated Resident A's pressure sore to his sacrum will get worse due to pressure on the sacrum when the resident was lying on his back in bed. They stated the facility's "Patient Repositioning Schedule" to turn and reposition the resident at least every two hours should be followed by the CNA to prevent further skin breakdown and to heal the pressure sore. The DON stated the RN Supervisor, Charge Nurse and the Treatment Nurse were responsible for monitoring the resident every two hours to ensure Resident A was turned and repositioned in bed. The DON stated there was no written documentation that Resident A was monitored by the staff that he was turned and repositioned in bed every two hours. The DON was not aware the resident's pressure sore had yellow drainage since 11/5/15, and the physician had assessed the resident's sacrum as stage III pressure sore on 1/31/16. The DON stated the "Weekly Decubitus Update" she received from Treatment Nurse 1 indicated Resident A had stage II pressure sore to his sacrum. Treatment Nurse 1 was on medical leave. Treatment Nurse 2 stated he did not inform CNA 1 that Resident A should not be turned and repositioned on his back while in bed. During an interview on 3/17/16 at 9:40 a.m., RN 1 stated she informed CNA 1 that Resident A should be turned and repositioned only to his right side and left side while in bed to avoid pressure on the resident's sacrum pressure sore. During an interview on 3/18/16 at 8:10 a.m., Resident A's wife stated she visited the resident three times a day to feed him during meal times. She was aware the resident had a pressure sore to his sacrum. She always arrived in the facility at 6:30 a.m., and the resident was observed lying on his back most of the time while in bed. The facility failed to: 1. Revise the Plan of Care to address the frequency in which the resident should be turned, as well as positioning the resident while in bed. 2. Ensure the resident was not lying on his back directly on the pressure sore. 3. Accurately assess the skin condition of sacrum (a triangular shaped bone at the bottom of the spine) pressure sore. 4. Monitor and report skin changes to the physician. As a result, Resident A developed an avoidable stage III pressure sore to his sacrum. The facility?s failure to prevent the development and progression of pressure sore to a resident who was at risk for pressure sores resulted in Resident A to develop an avoidable stage III pressure sore to his sacrum. This above violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 970000066 |
THE CALIFORNIAN - PASADENA CONVALESCENT HOSPITAL |
950013240 |
B |
31-May-17 |
5PU211 |
13192 |
F314
?483.25(c) Treatment/Services to Prevent/Heal Pressure Ulcers
Based on the comprehensive assessment of a resident, the facility must ensure that ?
(1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and
(2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.
On 4/27/17 at 7:40 p.m., an unannounced visit was made to the facility to conduct an annual recertification survey.
Based on observation, interview and record review, the facility failed to provide the necessary care and services, for Resident 1, to prevent the development of a pressure sore (localized injury to the skin and underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and or/friction) by failing to:
a. Implement the physician?s order to place the nasal cannula (NC, tubing used to deliver oxygen via nostrils) padding to the back of Resident 1's ears to provide pressure relief to the area.
b. Develop a care plan for when Resident 1 refused to wear the NC padding and provide alternative interventions to provide pressure relief to the ear.
c. Document skin integrity checks to the back of the ears on a daily basis to identify any skin damage to be addressed.
These deficient practices resulted with Resident 1 developing a pressure sore to the back of the right ear. After the pressure sore was identified the facility failed to:
d. Accurately assess a wound as a pressure sore in order to provide treatment and services.
e. Notify Resident 1?s physician of the wound as a pressure sore.
These deficient practices had the potential to delay Resident 1?s necessary treatment for a pressure sore.
A review of the face sheet (document that gives a resident?s information at a quick glance) indicated Resident 1 was an 89 year old female admitted to the facility on XXXXXXX15, with diagnoses of pneumonia (infection that inflames the lungs), atrial fibrillation (two upper chambers of the heart beat irregular), hypertension (high blood pressure), anxiety disorder (have intense, excessive and persistent worry and fear about everyday situations), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of the Minimum Data Set (MDS, standardized assessment and care screening tool) dated 2/21/17 indicated Resident 1 was at risk for developing pressure ulcers.
A review of the Braden Scale (scale used for predicting Pressure Sore Risk assessment tool) dated 2/20/17 indicated Resident 1 was at high risk for developing pressure sores. Resident 1 score was a 10, (total score of 12 or less represents high risk).
A physician's order dated 6/2/16, indicated Resident 1 required three liters of oxygen via a nasal cannula (NC, tubing used to deliver oxygen) for shortness of breath with padding to the back of the ear tubing.
On 4/27/17, at 9:39 p.m., during an observation Resident 1 was lying in bed with a NC in place. Resident 1?s head was turned toward the right side, lying on her right ear. There was no padding in place to the part of the NC in the back of the ear.
On 4/27/17, at 9:40 p.m., an interview was conducted with Resident 1's Responsible Party (RP). RP stated Resident 1 had refused placement of the NC padding and that Resident 1 preferred to lie down on her right side. There was no care plan developed for this behavior (refusal of padding) found in Resident 1's medical record.
On 4/27/17, at 9:43 p.m., an observation was conducted and Resident 1 had the NC in place. The skin to the back of the right ear and alongside the NC, was red and swollen, there was crust (a formed outer layer, especially of a solid matter formed by drying of a bodily fluid or secretion) touching the skin and over the tubing with mild weeping (slow discharge from a wound) fluid. The back of both ears were compared and the back of the right ear was enlarged. In addition, the NC tubbing under Resident 1's chin was pulling toward the left and pulling the portion located behind the right ear. There was no documented evidence the staff assessed the skin underneath the NC device behind the ears.
On 4/27/17, at 9:43 p.m., Resident 1 stated her right ear hurt whenever someone pulled the NC tubing.
On 4/27/17, at 10:02 p.m., an interview was conducted with Licensed Vocational Nurse 1 (LVN 1) who was caring for Resident 1. She stated Resident 1 was not one of her residents with a pressure ulcer.
During a subsequent observation of Resident 1, on 4/27/17, at 11:09 p.m., Resident 1?s NC had padding. The function of the padding is to help prevent local skin damage caused by the pressure of the tubing.
On 4/27/17, at 11:10 p.m., LVN 1 was asked if she had placed the padding of Resident 1's NC behind the ears and stated, "Yes." LVN 1 was asked if she assessed the back of the right ear and she stated "Yes, it's just red." LVN 1 stated Resident 1 always refused placement of the NC padding to the back of her ears and staff had tried to wrap the tubing with gauze a few times.
On 4/27/17, at 11:15 p.m., a second observation was conducted of Resident 1's right ear; LVN 1, RN 1, and Surveyor 2 were present. Resident 1 was completely turned toward the left side and a flashlight was used during the assessment. Resident 1's NC was removed and the back of her ear had an open wound (the length correlated with the location of the NC), redness around the wound and redness directly behind the ear with a mild amount of purulent (light yellow) drainage present, and swelling to the back of the ear.
During an interview on 4/27/17, at 11:16 p.m., RN 1 stated Resident 1's back of the ear had yellow drainage, redness, swelling, and the skin was open.
A review of the physician's order dated 4/27/17, at 11:40 p.m., indicated to observe the back of the right ear on a daily basis and cleanse with normal saline (sterile water) or wound cleaner with the application of hydrogen gel (gel used for wounds).
A review of LVN 1's notes dated 4/28/17, at 12:40 a.m., indicated "resident complained of pain in right ear noted with redness." There was no documentation of the drainage and open wound.
On 4/28/17, at 7:52 a.m., an interview was conducted with the director of nursing (DON). The DON stated the Resident 1 had refused to wear the NC paddings and this behavior was not care planned. The DON stated the staff should develop a care plan for a resident who resists care because if no interventions are developed it can result in a poor resident outcome.
On 4/28/17, at 8:16 a.m., an interview was conducted with RN 2. RN 2 stated on 4/27/17, after the survey team had left, she was asked by the facility to perform a second assessment to the back of Resident 1's ear, "I didn't see anything." RN 2 stated she put A & D ointment (topical skin protectant) to the back of the ear. There was no physician's order for A & D ointment or evidence that it was administered in the Medication Administration Record (MAR).
After the identification of the wound to the back of the right ear the facility failed to properly assess the wound as a pressure sore, as follows:
A review of RN 2's notes dated 4/28/17, at 8:41 a.m., indicated a late entry for 4/27/17, at 10:00 p.m. The documentation indicated the back of the right ear had "mild pinkness, dry, [and] no breakdown noted." There was no prior documentation on the condition of the ear prior to this late entry.
On 4/28/17, at 8:23 a.m., a third observation to the back of Resident 1's ear was conducted with RN 2, DON (director of nursing), and TN 1 present. The back of Resident 1's ear had an open wound; the skin was pink, and swollen.
A review of RN 2's notes dated 4/28/17, at 9:00 a.m., indicated "follow up assessment of behind right ear. Behind right ear redness and pinpoint size ulcer note without drainage."
On 4/28/17, at 8:25 a.m., an interview was conducted with the DON, she stated the back of Resident 1's ear had open skin, was pink, and the ridge was bigger than the left ear.
On 4/28/17, at 8:32 a.m., TN 1 cleaned the wound with normal saline and then measured Resident 1's wound with a cotton swab. As TN 1 was measuring the wound, he verbalized the following: length 1 centimeter (cm), width 0.2 cm, and depth 0.3 cm. TN 1 stated Resident 1's skin to the back of the ear was open and pink. TN 1 further stated the tubing of the NC could cause pressure to the back of the ears.
A review of TN 1's notes dated 4/28/17 indicated the tissue was red. The skin issue type was documented as an "Abrasion/irritation-minor (an injury caused by something that rubs or scrapes against the skin; a superficial damage to the skin)."
According to the National Pressure Ulcer Advisory Panel (NPUAP) dated 2/23/15, indicated that Medically Related Pressure Ulcers are "pressure ulcers that result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure ulcer generally closely conforms to the pattern or shape of the device." The number one locations where these pressure ulcers occur are: head, neck, face, and ears. Oxygen delivery via nasal cannula is pressure ulcers waiting to happen. The recommendation for best practices for assessment of skin and medical devices "Inspect skin and under medical device at least twice daily ideally more frequently? and for general preventive care "View skin under devices each shift, lift the device and reposition, use skin protectant. The strategies for pressure ulcer prevention for the use of oxygen tubing "watch ears, move hair [and] use tubing protectors."
http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/
A review of the facility policy for Prevention of Pressure Ulcers revised 9/13, indicated that ?Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears. If pressure ulcers are not treated when discovered, they quickly get larger and often times become infected. 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.?
A review of DON's notes dated 4/28/16, at 8:44 a.m., indicated "On assessment with treatment nurse, area behind right ear noted. Small area with a small, narrow, broken area, clean, dry, no exudate, and pink in color. Ear shape has a protuberance (usually rounded part that sticks out from a surface) on that side somewhat more than the left side.
On 4/29/17, at 6:10 a.m., an interview was conducted with RN 1. RN 1 stated LVN 1 notified the physician of Resident 1's condition and obtained an order for the treatment of an abrasion. RN 1 failed to notify the physician of Resident 1?s actual condition (development of a pressure sore with yellow drainage) by not endorsing or documenting her assessment of Resident 1's ear. RN 1 further stated the yellow drainage observed on Resident 1's ear was A & D ointment placed by RN 2. The information provided by RN 1 about the A & D ointment application was not consistent with the time provided by RN 2 in an interview on 4/28/17 at 8:16 a.m., of when she applied the A&D ointment.
On 4/29/17, at 6:58 a.m., an interview was conducted with LVN 2. LVN 2 stated it is facility practice when residents require the use of a NC for oxygen delivery a gray pad is placed to the tubbing behind the ears. The purpose of the padding to the back of the ears is to prevent redness and sores. LVN 2 stated that the NC could cut the skin and cause pressure sores. The refusal of NC padding by a resident, places them at greater risk for pressure sores, they are to receive education and a care plan should be developed. LVN 2 stated residents who refuse the paddings to the back of the ears should be checked on a daily basis.
The facility failed to implement the physician?s order and apply NC padding to the back of Resident 1?s ears, develop a care plan, implement alternative interventions to protect the skin behind the ears, and document daily skin integrity checks to identify skin damage. As a result, Resident 1developed a pressure sore to the back of the right ear. In addition, after the pressure sore was identified the facility failed to accurately assess the pressure sore and notify the physician of the development of the pressure sore. This had the potential to result in a delay with Resident 1 necessary treatment for the development of a pressure sore.
The above violations had a direct or immediate relationship to Resident 1?s health, safety, or security. |
| 960001809 |
TEMPLE GARDEN HOMES |
960012836 |
A |
6-Jan-17 |
2FP711 |
8226 |
Title 22: 76918 Clients Rights
(a) Each client shall have those rights as specified in sections 4502 through 4505 of the Welfare and Institution Code.
4502(h) Welfare and Institutions Code
Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which received public funds.
It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following:
(h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect.
On 11/1/16 at 6:50 a.m., an unannounced visit was made to the facility to investigate an entity reported incident.
The facility's staff failed to protect Client 1 from harm, by failing to implement an objective for Client 1. Client 1 started to have an episode of stiffness and refused to move; Direct Care Staff (DCS 1) sat the client in an upright position on the edge of his bed and left the client by himself, to get a shower chair, to transport the client to the living room. According to Client 1?s objective, DCS 1 should have placed the client into bed. This failure resulted in Client 1 falling face down on the floor and sustaining a fracture of the right nasal bone (nose fracture).
During an observation on 11/1/16, at 7 am, Client 1 was nonverbal and able to ambulate around the house with staff's assistant.
During an interview with DCS 2, on 11/1/16, at 7:15 am, he stated DCS 1 was no longer working at the facility. DCS 2 stated DCS 1 was transferred to a sister facility.
A review of Client 1's clinical record indicated the client was admitted to the facility on XXXXXXX12 with diagnoses that included profound intellectual disability (significant developmental delays in all areas and incapable of self-care), early onset meningitis (infection of the protective membranes of the brain and the spinal cord that occurred within one week after birth), incidents of anxiety (feeling of worry, nervousness) and unsteady gait.
During an interview with DCS 2, on 11/1/16, at 7:30 am, he stated on 10/16/16, at around 6 am, DCS 1 knocked on his office door and informed him that Client 1 fell on the floor. DCS 2 stated when he entered Client 1's room, he saw the client was lying in bed with a nose bleed and an ice pack was on top of the client's nose. DCS 2 stated according to DCS 1, when DCS 1 was assisting Client 1 with ambulating from the client's bed to the living room, the client took a couple steps then the client started to have an anxiety attack. DCS 2 stated when Client 1 had an anxiety attack, the client would become disoriented, the client's body would stiffen up for a couple of minutes and he would not walk or do anything. DCS 2 stated DCS 1 sat the client down at the edge of the bed and walked away to get a shower chair to wheel Client 1 to the living room. DCS 2 stated before DCS 1 could get to the shower chair, he heard a "thud" sound and found Client 1 face down on the floor. DCS 2 stated the facility's Licensed Vocational Nurse (LVN) advised him to take Client 1 to the hospital's Emergency Room (ER) for further evaluation. DCS 2 stated at the ER, the doctor ordered computerized tomography scans (CT scan, a combination of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones) of the facial bone and the brain. DCS 2 stated at around 11 am, the CT scans results confirmed that Client 1 sustained a thin fracture of the nose.
A review of the ER's radiology report, dated 10/16/16, indicated Client 1 came to the hospital's ER with some external injury/trauma. CT images of the facial bones were obtained and the result showed fracture of the right nasal bone with minimal displacement.
A review of the nurse?s note, dated 10/16/16, indicated Client 1 fell face down on the floor resulting in a nose bleed. The client was sent to a hospital's ER and was discharged back to the facility on the same date with diagnosis of nasal fracture. The note further indicated to continue to place an ice pack on Client 1?s nose and continue to give Tylenol/Motrin as directed for pain.
During an interview with DCS 2, on 11/1/16, at 8:00 am, he stated Client 1 was admitted to the facility with history anxiety attack episodes. DCS 2 stated before Client 1 was admitted to the facility, the client's family member told us about the client's anxiety attacks and the interventions during those attacks. DCS 2 stated Client 1's family member made sure staff knew what to do before transferring the client to the facility. DCS 2 stated whenever Client 1 had an anxiety attack; staff cannot leave the client by himself. DCS 2 stated if for some emergency reason when staff need to leave Client 1 by himself during an anxiety attack, the staff needed to make sure the client was in a secure position first so the client couldn?t fall. DCS 2 stated a secure position means when the client was lying down on the floor or sitting/lying further on the bed, not at the edge of the bed.
During an interview with DCS 1, on 11/1/16, at 8:30 am, he stated on Sunday morning (10/16/16) at about 5:30 am, Client 1 was weak and could not walk. DCS 1 stated he walked away from Client 1 to grab the shower chair in-order to take the client to the Livingroom using the shower chair. DCS 1 stated as he took a couple of steps away from the client he heard a "thud" sound. DCS 1 stated when he turned around; Client 1 was already on the floor, face down. DCS 1 stated he was trained not to leave Client 1 alone when the client was experiencing a seizure/anxiety episode (seizure is a sudden surge of electrical activity in the brain that usually affects how a person feels or acts for a short time). DCS 1 stated "It was an honest mistake" because he was a new employee and he was rushing to get everything done. DCS 1 stated he should not leave the client alone.
During an interview with the Qualified Intellectual Disability Professional (QIDP), on 11/1/16, at 9:38 am, he stated Client 1's family's member called Client 1's episodes as seizure episode, but the facility's neurologist called those episodes as anxiety attacks. The QIDP stated we do not know how, why or where, those attacks come from.
A review of Client 1's Individual Service Plan (ISP) from December 2015 to November 2016 indicated the client had an objective to be calm and not stiffen, without episodes of stiffness or catatonia (abnormality of movement and behavior arising from a disturbed mental state). The staff's implementation steps include:
1. Provide a calming environment to the client
2. Talk to the client; touch the client on the shoulder to reassure him.
3. Try to get the client to bed if the client cooperates.
4. Determine how long the client was stiffened.
5. Chart the duration in seconds or minutes before the client calms down.
6. Praise the client if he responds.
8. Staff may call the client's family member at any time for any prolonged catatonic reaction.
The facility's staff failed to protect Client 1 from harm, by failing to implement an objective for Client 1. Client 1 started to have an episode of stiffness and refused to move; Direct Care Staff (DCS 1) sat the client in an upright position on the edge of his bed and left the client by himself, to get a shower chair, to transport the client to the living room. According to Client 1?s objective, DCS 1 should have placed the client into bed. This failure resulted in Client 1 falling face down on the floor and sustaining a fracture of the right nasal bone.
The above violation presented either an imminent danger that death or serious physical harm would result or a substantial probability that death or serious physical harm would result. |
| 960001498 |
TLC - LINDLEY II |
960013269 |
B |
8-Jun-17 |
F8XX11 |
4548 |
Title 22: 76845
The securing of criminal records shall be accordance with the provisions of Section 1265.5 of the Health and safety Code.
1265.5 (f)
(f) Upon the employment of any person specified in subdivisions (a), and prior to any contract with clients or residents, the facility shall submit fingerprint cards to department for the purpose of obtaining a criminal record check.
On 5/17/17, an unannounced visit was made to the facility to conduct a re-certification survey.
Based on observation, interview and record review, the facility's administrative staff failed to:
Ensure criminal record clearance from the Department of Justice (DOJ) was obtained for one Direct Care Staff (DCS 1) to screen for history of abuse prior to DCS 1 working and caring for the 11 clients who reside in the facility. This failure had the potential for not ensuring the safety and well-being for all the clients.
During an observation, on 5/17/17, at 6 am, the facility's population consisted of 11 clients who depend on staff for assistance in the basic activities of daily living.
During a review of the "Client Roster Information," dated 5/17/17, indicated Clients 1, 2, 4, 6, 7, 9, 11 had a diagnosis of mild intellectual disability (slower than typical in all developmental areas). Clients 3 and 8 had a diagnosis of moderated intellectual disability (developmentally functions below chronological age and can learn elementary health and safety habits) and Client 10 had a diagnosis of profound intellectual disability (significant developmental delays in all areas and incapable of self-care).
During an observation, on 6:04 am to 8:07 am, DCS 1 was assisting Client 2 with morning care and with activities of daily living including getting the client ready for breakfast.
A review of DCS 1?s personnel files, on 5/17/17, at 11:20 am, indicated DCS 1 was hired on 9/12/16. Further review of DCS 1?s personnel files, indicated there was no criminal record clearance letter available for review.
On 7/17/17, at 12:40 am, the surveyor called the Interactive Voice Response Unit (IVRU), at the DOJ office. The response was there was no application on record for the live scan (fingerprint clearance) for DCS 1 to work in the Intermediate Care Facilities (ICF).
Further review of DCS 1?s personnel files, on 5/17/17, indicated the Caregiver Background Check Bureau sent a letter to the facility, titled "Immediate Action Required," dated 8/31/16, indicated DCS 1 needed a criminal record exemption. The letter indicated DCS 1 cannot work or be present in the facility until he has obtained a criminal record exemption. The letter indicated DCS 1 must submit the documents within forty five days of this notice or DCS 1's file will be closed. The letter indicated if DCS 1?s file is closed, he must resubmit fingerprints, at an additional cost, to begin the process again.
During an interview with the facility's Qualified Intellectual Disability Professional (QIDP), on 5/18/17, at 2:40 pm, she stated there was a change in human resource (HR) personnel during the time DCS 1 was hired and someone forgot to submit the requested documentation to the DOJ within the 45 day time frame. The QIDP stated the new HR staff thought the requested documentation was sent to the DOJ but it has not been sent. The QIDP further stated it is the facility's policy for all staff to receive criminal record clearance prior to taking care of the clients.
According to the "Immediate Action Required Criminal Record Exemption Needed" for DCS 1, dated 8/31/16, indicated the facility must respond regarding whether or not DCS 1 will continue with employment and submit the required documentation. Further review of DCS 1's employee file, indicated there was no supportive documentation provided by the facility indicating that the facility responded to the notice as required.
A review of the facility's policy and procedure titled "Facility Systems to Prevent Abuse and Neglect," indicated the fundamental responsibility of every employee of the program is the safety and well-being of each client.
The facility's administrative staff failed to ensure criminal record clearance from the DOJ was obtained for DCS 1 to screen for history of abuse prior to him working and caring for 11 clients who reside in the facility. This failure had the potential for not ensuring the safety and well-being for the clients.
The above violation had a direct relationship to the health safety and security of clients. |
| 960001498 |
TLC - LINDLEY II |
960013419 |
B |
10-Aug-17 |
8ZZN11 |
6444 |
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 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. 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 of 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 February 10, 2017 at 8:00 a.m., an unannounced visit was made to the facility to investigate an entity reported incident of an alleged incident of abuse regarding Client 8.
The facility failed to implement their abuse policy and procedure by failing to:
1. Ensure staff did not use verbal abuse when assisting Client 8 with his personal hygiene needs.
2. Ensure staff did not mistreat Client 8 when assisting him with his personal hygiene needs.
The clinical record for Client 8 was reviewed on February 10, 2017. The face sheet indicated Client 8 was admitted to the facility, on XXXXXXX 1992, with diagnoses that included mild intellectual disabilities (developmentally functions below chronological age, is slow in all areas, but can acquire practical and vocational skills) and blindness (the state or condition of being unable to see because of injury, disease, or a congenital condition). Client 8 is ambulatory and verbal.
During an observation on February 10, 2017, at 8:45 a.m., in the area adjacent to the living area, Client 8 was sitting in a recliner chair.
During an interview with Client 8, on February 10, 2017, at 8:50 a.m., he stated he did not want to talk at this time.
During an interview with Staff A, on February 10, 2017, at 10:45 a.m., she stated on January 10, 2017, at 6:42 p.m., she was in the kitchen cooking when all of a sudden, Staff C was standing in the hallway outside of Client 8's bedroom and loudly stated, Client 8 urinated on himself and he was wet. Staff A stated the other clients and staff were able to hear the announcement as they were in the sitting area nearby. She stated Staff B was eating at the dining table, abruptly stood up, went to Client 8's bedroom and started screaming at Client 8. Staff A stated Staff B stood behind Client 8 screaming and yelling as she was yanking and pulling up on Client 8's pants which lifted his feet up off the floor. Staff A further stated Staff B said in an angry tone "You are not a baby here; we always wash a lot of clothes for you!" and Client 8 stopped moving around because he was intimidated. Staff B stated, "We do not have babies here, what is wrong with you guys always peeing and pooping" "Come on, let us go and you sit in the living room until 9:00 p.m.," then Staff B, interlocked her arm with Client 8's arm and aggressively walked him from his room down the long hallway to his recliner chair and stated in an angry tone "You are going to stay here until 9:00 p.m." Staff A stated Client 8 sat in his recliner chair with his elbow on the armrest and his head resting on his open hand and he did not say anything as he was normally talkative, but he was sad. Staff A stated with the former qualified intellectual disabilities professional (QIDP), she would put her concerns about the facility, in the administration suggestion box for someone to come to the house as she felt things going on in the facility were catastrophic.
On February 10, 2017, Staff B and Staff C were not available for interview.
During an interview with the QIDP, on February 10, 2017, at 5:45 p.m., she stated Staff A informed her and the Residential Director of the incident that occurred on January 10, 2017. The QIDP stated an investigation was immediately conducted. She stated Staff B was suspended, taken off the schedule and Staff B resigned.
A review of documented interviews conducted by the QIDP and Residential Director during their internal investigation indicated the following:
1. On January 30, 2017, Staff D stated Staff B talks loud and Staff C waits to find an issue until it is too late and then will announce it to the whole facility what is wrong.
2. On January 31, 2017, Staff E stated the tone of voice Staff B used when talking to the clients was not appropriate. Staff E stated Staff B spoke to the clients in a loud and directive way which made himself feel uncomfortable.
The employee file for Staff B was reviewed. There was a document titled "Rights of the Developmental-Disabled," signed and dated, January 8, 2013 by Staff B, indicating Staff B was aware of the client's rights which included, a right to be free from harm and abuse.
The facility policy and procedure titled "Facility Systems To Prevent Abuse and Neglect" dated March 2014, indicated forms and definitions of abuse which include mental, physical, any physical harm, or mental suffering.
Definitions of abuse of an elder or a dependent adult, included the following:
Mental Abuse: Deliberately inducing fear, agitation, confusion, severe depression, or other forms of serious emotional distress through verbal assaults, threats, harassment, or other forms of intimidating behavior.
Physical Abuse: Assault, battery, sexual assault, assault with a deadly weapon or force likely to produce great bodily injury, unreasonable physical restraint.
The facility failed to implement their abuse policy and procedure by failing to:
1. Ensure staff did not use verbal abuse when assisting Client 8 with his personal hygiene needs.
2. Ensure staff did not mistreat Client 8 when assisting him with his personal hygiene needs.
These violations caused or occurred under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to clients. |
| 980002508 |
THE CENTER FOR DISCOVERY AND ADOLESCENT CHANGE |
980011777 |
B |
08-Oct-15 |
ZRL811 |
5147 |
? 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. On August 4, 2015, at 2 p.m., an unannounced visit was made to the facility to investigate a complaint regarding Patient 1 was subject to abuse by the facility staff. According to the complaint, Patient 1 entered a restaurant running and crying hysterically asking to allow him to use the telephone because the people following him were hurting him. The complainant (witness) indicated the two persons following the patient grabbed him, poorly handled, and mistreated him.Based on interviews and record review, the facility failed to ensure Patient 1 had the right to be free from physical and mental abuse by failing to: 1. Ensure Patient 1 was not physically and mentally abused by Staff 6 who yanked him off the fence and threw him to the ground and by Staff 2 and 3, who while taking Patient 1 back to the facility from a nearby business, grabbed him, forcefully remove a telephone from him and spoke, poorly handled, mistreated him. As a result, the patient was tearful and scared.2. Ensure a policy and procedure on abuse prevention was established and implemented. The facility's patient population ages range from 11 to 19 years old and all have behavioral problems.On August 4, 2015, upon entrance to the facility and during an interview with the Director of Operations, a copy of the facility's policy and procedure on abuse prevention was requested. The Director of Operations stated an abuse policy was currently being developed. The facility did not have any policy on abuse.A review of the Patient 1's clinical record indicated and admission to the facility on July 30, 2015, with diagnoses including anxiety and unstable mood. The clinical record indicated on August 1, 2015, a day after admission, on three occasions Patient 1 attempted to leave the facility without permission (AWOL-absence without leave) by climbing over the fence.A review of the Shift Notes dated August 1, 2015, timed 7:30 a.m. to 3:30 p.m. shift, indicated Patient 1 continued asking to call his dad and walked around crying about not being able to use the phone. Patient 1 attempted to leave the facility (no time specified) by climbing over a fence and became stuck. Staff 6 assisted Patient 1 from the fence and back into the facility. A review of the Shift Notes dated August 1, 2015, timed 3 p.m. to 11 p.m. shift, indicated Patient 1 climbed over the fence and entered a nearby restaurant approximately 9 p.m. Staff followed him and the police (called by the staff) escorted Patient 1 back to the facility.On August 4, 2015, at 2:30 p.m., during an interview, Patient 1 stated he wanted to talk to his dad and the staff told him, "No" that he could not call his dad due to the 72-hour rule of no calls. Patient 1 stated as he tried to climb over the fence, Staff 6 yanked him off the fence and threw him to the ground. Patient 1 stated when he was able to leave the facility, he used the telephone at the nearby restaurant but staff (did not specify who) yanked the telephone from him. Patient 1 also stated he was crying and very upset until he was able to speak with his dad, then he calmed down. Patient 1 stated he was scared being in the facility.On August 4, 2015, at 2:46 p.m., during an interview, the Director of Operation stated the facility did not have a 72-Hour No Call policy but it was a facility?s rule. A review of the facility?s policy and procedure on AWOL Response revised on March 23, 2010, indicated, ?If the client begins to run, the staff will not pursue him/her, will return to the facility and communicate with to the police the location of and direction the client was heading.?From August 4, 2015, at 2:55 p.m. to August 7, 2015, at 3:30 p.m., Staff 1- 6 were interviewed regarding the facility's educational program and abuse prevention policy and procedures. Staff 1, 2, 3, 4, 5, and 6 stated they had not received abuse prevention training or an orientation in the facility's policy on abuse prevention.The facility failed to ensure Patient 1 had the right to be free from physical and mental abuse by failing to: 1. Ensure Patient 1 was not physically and mentally abused by Staff 6 who yanked him off the fence and threw him to the ground and by Staff 2 and 3, who while taking Patient 1 back to the facility from a nearby business, grabbed him, forcefully remove a telephone from him and grabbed him, and mistreated him. As a result, the patient was tearful and scared.2. Ensure a policy and procedure on abuse prevention was established and implemented.The above violation had direct or immediate relationship to the health, safety, or security of Patient 1. |
| 980002508 |
THE CENTER FOR DISCOVERY AND ADOLESCENT CHANGE |
980011855 |
A |
19-Nov-15 |
ZQM811 |
8846 |
? 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. On 8/26/15, an unannounced visit was made to the facility to investigate a complaint regarding Patient Abuse. Based on interviews and record review, the facility failed to ensure Patient 2 had the right to be free from physical abuse by failing to: 1. Ensure Patient 2 was not physically abused by Patient 3, who had a fight with Patient 2.2. Ensure a policy and procedures on abuse prevention were established and implemented. 3. Failed to ensure the staff received an educational program and training in abuse including identification, prevention, protection, reporting, and investigation.As a result, Patient 2 sustained a broken right arm after being attacked by Patient 3. Patient 2 was not protected from physical abuse from Patient 3. In addition, the incident of abuse resulting in physical harm to Patient 2 was not reported to the Department.The facility's patient population age ranges from 11 to 19 years of age and all have behavioral problems.According to the clinical record Patient 2 was admitted to the facility on 11/3/14, with diagnosis included psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), depressive disorder (persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities), and attention deficit hyperactivity disorder (ADHD).According to the Biopsychosocial Assessment, dated 11/3/14, the patient had a history of verbal and physical aggression and emotionally, physically and sexually abused. The Initial Treatment Plan indicated a problem list of inappropriate boundaries with others and anger issues. A review of the Psychiatrist Progress Notes indicated on 11/17/14, the patient was irritable in reaction to peer conflict. According to the Progress Notes (therapist notes) dated 11/21/14, the patient was angry and despondent following an incident involving a conflict between peers. A review of the Shift Notes (counselor notes) indicated the following incidents and behaviors: On 11/24/14, patient (Patient 2) threatened to cause physical harm to another patient. On 11/28/14, patient (Patient 2) got into a fight at the park with a male (Patient 3). On 12/6/14, patient (Patient 2) came from his room with an injured arm, reporting a peer (Patient 3) pushed him, as the patient held his arm out behind him for support; his arm hit the wall with a good amount of force. The patient (Patient 2) was seen by the nurse and was sent to the general acute care hospital (GACH). The patient called his mother to explain the incident. A review of the Discharge Summary dated 12/6/14, indicated the patient was discharged against medical advice and against clinical advice after a physical altercation with another patient resulted in hospitalization for a broken arm.A review of the GACH emergency room admission note dated 12/6/14, the patient presented to the emergency department (ED) with complaint of the upper extremity pain. The patient was pushed by another individual and fell. Gross deformity of the right forearm, soft tissue swelling and tenderness to palpation was noted. The X-ray indicated a fracture of the mid shaft radius (one of the two large bones of the forearm) and a small avulsion fracture of the ulnar (the other large bone of the forearm) styloid process (the tip of the ulna at the wrist area).A review of the Patient 3's clinical record indicated an admission dated 10/17/14 with diagnosis including impulse- control disorder, disruptive mood and major depressive disorder.A review of Patient 3's Progress Notes 3 indicated the following behaviors: On 11/20/14, the patient felt urges to harm another patient and threatened to break the patients' ribs.On 11/27/14, the patient appeared angry, clenching his fist and expressing anger toward a male peer/patient. On 11/28/14, the patient had a fight with a male peer/patient and he threatened to kill the peer and himself. On 11/29/14, the patient was angry and upset due to privileges being taken because of previous fight. On 12/5/14, the patient presented with anxious to angry mood and displayed aggressive behavior. On 12/6/14, the patient was cursing excessive, threatening peers/patients; the patient went into another patient's room, punched the patient and got into a fight with a patient. On 12/7/14, the patient was aggressive, initiating physical fights, injured his hand from punching the wooden shelves and tried to self-harm - 12/8/14, the patient was in an irritable-angry mood state and was hurting due the problem in the hand. - 12/9/14, the patient was assessed by the Psychiatric Evaluation Team (PET) and was transferred out of the facility.On 8/28/15, at 1:45 p.m. during an interview, the Program Director stated the staff needed more training regarding abuse. When the facility's policy and procedure on abuse was requested, the Program Director stated an abuse policy was currently being developed. On 9/15/15, at 2 p.m., during another interview, the Program Director stated the limits of sharing information is followed, the only time information is shared/ reported is when patient is an immediate danger or a danger to someone. On 9/15/15, at 3:30 p.m., during an interview, Staff 2 stated she began working at the facility on 6/29/14, and denied having abuse training. Staff 2 stated she had no prior experience working with minor patients who have behavioral problems. On 9/18/15, at 3:30 p.m., during an interview, Staff 4 stated she did not receive abuse training upon hire in 2007.On 9/18/15, at 3:40 p.m., during an interview, Therapist 2 stated he received abuse training in other health facilities he worked. Therapist 2 further stated this was his first time working with minors. Therapist 2 stated Patient 2 was discharged due to behaviors and altercations with others and following a fracture of his arm.On 9/21/15, at 12:05 p.m., during a telephone interview, Patient 2's responsible party stated the patient had previous fights with Patient 3. The facility staff never notified her of the incidents or informed her of the details. Patient 2 made her aware and she decided to take him out of the facility due to the fights, conflicts with the roommate, and the broken arm.On 9/23/15, at 10:35 a.m., during a telephone interview, Patient 2 stated that during an outside activity at a park (11/28/14), he had a fight with a patient (Patient 3) who kicked him in the stomach and then he bit Patient 3 on the chest. Staff was not present in the area to witness the fight. When both (Patients 2 and 3) returned to the facility, staff was made aware of the altercation. Patient 2 added that on another day (12/6/14), when there were only two staff on duty in the area and one of them was pregnant, Patient 3 followed him into his room (Patient 2?s), launched at him causing him to fall back, hit the wall, and broke his arm. Patient 2's told a male staff Patient 3 broke his arm. Further record review of Patients 2 and 3 failed to have documentation of planned interventions, or measures implemented to protect Patient 2 from further abuse and prevent further physical altercations between Patients 2 and 3. The facility did not have documented investigation of patient 2?s allegation of abuse resulting in a broken right arm and did not have evidence of a report made to the Department regarding the abuse.The facility failed to ensure Patient 2 had the right to be free from physical abuse by failing to: 1. Ensure Patient 2 was not physically abused by Patient 3, who had a fight with Patient 2.2. Ensure a policy and procedures on abuse prevention were established and implemented. 3. Failed to ensure the staff received an educational program and training in abuse including identification, prevention, protection, reporting, and investigation.As a result, Patient 2 sustained a broken right arm after being attacked by Patient 3. Patient 2 was not protected from physical abuse from Patient 3 and the incident of abuse resulting in physical harm to Patient 2 was not reported to the Department.The above violation presented either an imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result to Patient 2. |
| 980002508 |
THE CENTER FOR DISCOVERY AND ADOLESCENT CHANGE |
980011856 |
B |
18-Nov-15 |
ZQM811 |
5690 |
? 72527. Patients' Rights. (a) Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (9) To be free from mental and physical abuse. On 8/26/15, an unannounced visit was made to the facility to investigate a complaint regarding Patient Abuse.Based on interviews and record review, the facility failed to ensure Patient 1 had the right to be free from physical and mental abuse by failing to: 1. Ensure Patient 1 was not sexually harassed/abused by Patient 2, who repeatedly had unwanted sexual advances towards Patient 1, such as kissing and touching.2. Ensure a policy and procedures on abuse prevention were established and implemented. 3. Failed to ensure the staff received an educational program and training in abuse including identification, prevention, protection, reporting, and investigation.As a result, Patient 1 felt uncomfortable, stressed and angry about Patient 2?s sexual advances and the staff who were aware of the abuse, did not protect Patient 1 from repeated abuse.The facility's patient population age ranges from 11 to 19 years of age and all have behavioral problems. A review of Patient 1's clinical record indicated an admission to the facility on 11/12/14, with diagnoses including major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and schizotypal personality disorder (a personality disorder characterized by a need for social isolation, anxiety in social situations, odd behavior and thinking, and often unconventional beliefs).A review of the Shift Notes dated 11/15/14, indicated the patient expressed anger toward those who molested her. On 12/1/14, Patient 1's commitment was a letter to her abuser (Patient 2), stating how uncomfortable she felt with his sexual harassment, the commitment letter was taken by the staff. A Progress Note dated 12/15/14, indicated that at the end of the group the patient processed aggressive behavior of male peer (Patient 2), expressed frustration related to perceived lack of discipline for male peers, and became very agitated and aggressive in speaking as evidence by raised voice.On 8/28/15, at 1:45 p.m. during an interview, the Program Director stated the staff needed more training regarding abuse. When the facility's policy and procedure on abuse was requested, the Program Director stated an abuse policy was currently being developed. On 9/15/15, at 3:20 p.m., during an interview, Staff 1 stated she should have reported the allegation on the date Patient 1 reported it to her. Staff 1 stated she was not clear who she should report the allegation to.On 9/15/15, at 3:30 p.m., during an interview, Staff 2 stated she began working at the facility on 6/29/14 and denied having abuse training. Staff 2 stated she had no prior experience working with minor patients who have behavioral problems. Staff 2 recalled documenting an incident between Patient 1 and a male patient (Patient 2).On 9/18/15, at 3:30 p.m., during an interview, Staff 4 stated she did not receive abuse training upon hire in 2007. Staff 4 recalled conflicts between Patients 1 and 2, and Patient 1 feeling uncomfortable about something Patient 2 said. Staff 4 indicated the conflicts between patients are reported to the therapist. On 9/18/15, at 3:40 p.m., during an interview, Therapist 2 stated he received abuse training in other health facilities he worked. Therapist 2 further stated this was his first time working with minors. Therapist 2 stated he was aware of Patient 2 hitting Patient 1 on the buttocks. Patient 2 was discharged due to behaviors and altercations with others and following a fracture of his arm.On 9/21/15, at 2:40 p.m., during an interview, Patient 1 stated Patient 2 touched her buttocks and kissed up and down her legs. There was staff in the area during each incident. The incidents caused her stress so she stayed away from Patient 2. Patient 1 felt this was sexual harassment yet the she felt the staff did nothing to stop it.On 9/23/15, at 10:35 a.m., during a telephone interview, Patient 2 stated Patient 1 was his friend; he liked her and he thought she liked him. Patient 2 admitted to kissing Patient 1 on her legs and arms and touching her buttocks.Further review of Patients 1 and 2?s clinical record disclosed no documentation of planned interventions or measures implemented to protect Patient 1 from further abuse. The facility did not have documented investigation of Patient 1?s allegations of abuse.The facility failed to ensure Patient 1 had the right to be free from physical and mental abuse by failing to: 1. Ensure Patient 1 was not sexually harassed/abused by Patient 2, who repeatedly had unwanted sexual advances towards Patient 1, such as kissing and touching. 2. Ensure a policy and procedures on abuse prevention was established and implemented. 3. Ensure staff received an educational program and training in abuse including identification, prevention, protection, reporting, and investigation.As a result, Patient 1 felt uncomfortable, stressed and angry about Patient 2?s sexual advances and the staff who were aware of the abuse, did not protect Patient 1 from repeated abuse. The above violation had a direct or immediate relationship to the health, safety, or security of Patient 1. |
| 040000064 |
TWILIGHT HAVEN |
040013534 |
B |
6-Oct-17 |
U4KL11 |
2434 |
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 when an allegation of abuse was not reported to the law enforcement agency and California Department of Public Health (CDPH) within 24 hours after the incident had occurred. This failure had the potential to affect the resident's safety and protection from harm.
Review of Resident 7's Minimum Data Set (MDS, an Assessment tool), dated 8/22/17, indicated the resident could make decisions and required assistance for transfers, dressing, hygiene, and bathing.
During an interview and record review with the director of nursing (DON) on 9/20/17 at 3:40 p.m., she stated Resident 7 made an allegation of abuse regarding certified nurse assistant A (CNA A), who got to the resident's knees, held her hands, and kissed her on the cheek. She also stated the allegation of abuse was not reported to the law enforcement agency and CDPH within 24 hours after the incident.
During an interview with the administrator on 9/21/17 at 8:45 a.m., she confirmed Resident 7's abuse allegation should have been reported to the law enforcement agency and CDPH within 24 hours.
Review of the facility's 9/2013 policy, titled "Abuse prevention program," indicated the administrator or his/her designee will report the alleged incident to the law enforcement agency and to CDPH within 24 hours.
The above violation has a direct or immediate relationship to the health, safety, or security of the resident. |
| 040000064 |
TWILIGHT HAVEN |
040013533 |
B |
6-Oct-17 |
U4KL11 |
7434 |
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 the environment was free of accident hazards for one resident (Resident 4) when staff did not ensure a pad alarm (a device applied to the bed surface that beeps when the resident tries to get up) was turned on. This failure resulted in Resident 4's fall, left hip fracture (cracked or broken left hip), skin tears on both elbows, and a cut on the left side of his forehead.
Resident 4's clinical record was reviewed. He was admitted on 12/27/16 and had diagnoses of dehydration (reduced amount of water in the body), anxiety, dementia (a mental disorder that impairs reasoning), and Alzheimer's disease (progressive mental deterioration).
A Minimum Data Set (MDS, an assessment tool), dated 4/4/17, indicated Resident 4 had moderate cognitive impairment and that he required cues and supervision to make decisions. The MDS also indicated Resident 4 required extensive assistance (staff provide weight bearing support) for transfers and was totally dependent (requires full staff performance) for moving on and off the unit.
A "Fall Risk Evaluation," dated 4/19/17, indicated Resident 4 had a fall risk score of 17 (a score of 10 or above represents high risk for falls).
Review of Resident 4's clinical record indicated he had a physician's order, dated 12/30/16, for a self-releasing belt with alarm (a seat belt that beeps when the resident unfastens it) while in the wheelchair. Resident 4 also had a physician's order, dated 1/8/17, for use of a pad alarm due to poor safety awareness.
A care plan, dated 4/10/17, indicated Resident 4 had multiple falls due to poor safety awareness. The care plan indicated Resident 4 was to have a self-releasing seat belt with alarm applied to his wheelchair and a pad alarm applied to his bed to alert staff when he tried to transfer without assistance.
A nurse's note, dated 6/27/17, indicated Resident 4 was found on the floor with skin tears on both elbows and a bleeding cut on the left side of his forehead. The nurse's note indicated that Resident 4's "bed alarm did not go off" at the time of the fall.
A nurse's note, dated 6/29/17, indicated Resident 4 complained of pain in his left leg, and that he was unable to move his left leg freely.
A "Radiology Report," dated 6/30/17, indicated Resident 4 had a nondisplaced left intertrochanter fracture (left hip fracture).
A nurse's note, dated 6/30/17, indicated Resident 4 was sent to the acute hospital for further evaluation related to a left hip fracture.
A "Discharge Summary" from the acute hospital, dated 7/3/17, indicated Resident 4 required open reduction and internal fixation (ORIF, a type of surgery) for the fracture of his left hip.
During an interview with the director of nursing (DON) on 9/20/17 at 9:20 a.m., she confirmed Resident 4 had a fall on 6/27/17 and was sent to the acute hospital on 6/30/17 due to a hip fracture. The DON stated that certified nurse assistant C (CNA C) was caring for Resident 4 on the day he fell. According to the DON, CNA C did not turn on Resident 4's bed pad alarm prior to the fall.
During an interview with licensed vocational nurse A (LVN A) on 9/20/17 at 11:05 a.m., she confirmed she was the nurse on duty during Resident 4's fall on 6/27/17. LVN A stated she responded to a yell for help and found Resident 4 on the floor lying on his side. According to LVN A, Resident 4 was in bed prior to the fall. LVN A stated Resident 4's bed pad alarm did not beep at the time of the fall, and that she did not remember if she checked if the bed pad alarm was turned on prior to the fall.
During an interview with the director of staff development (DSD) on 9/20/17 at 11:20 a.m., she stated CNAs and licensed nurses were responsible for checking if residents' alarms were on and functioning. The DSD further explained that licensed nurses should document that they have checked the alarms in the treatment administration record (TAR, record of treatment provided to the resident) once every shift. The DSD looked through Resident 4's clinical record and confirmed there was no documentation indicating Resident 4's bed pad alarm had been checked on the day of his fall, or for the entire month of 6/2017.
During an interview with the DON on 9/20/17 at 11:50 a.m., she stated CNA C did not follow Resident 4's plan of care because she did not turn on his bed pad alarm prior to his fall on 6/27/17. The DON stated CNA C was written up (a disciplinary action) because she did not follow Resident 4's plan of care. The DON also explained that licensed nurses were responsible for checking residents' alarms every shift and documenting this on the TAR. The DON looked through Resident 4's clinical record and confirmed there was no documentation indicating his bed pad alarm was checked for the month of 6/2017.
During an observation on 9/20/17 at 12:40 p.m., accompanied by the DON, Resident 4 was sitting in his wheelchair and wearing his self-releasing belt with alarm. The light on the alarm labeled "in use" was not blinking. The DON looked at the alarm switch and confirmed it was in the "off" position. The DON stated the alarm was off and that it should have been on. The DON flipped the alarm switch to the "on" position, the alarm made a loud beep, and the light labeled "in use" began to blink.
During a concurrent interview with the DON, she acknowledged that if Resident 4's bed pad alarm had been turned on at the time of his fall on 6/27/17, staff could have "possibly" assisted the resident before he fell.
During an interview with CNA C on 9/21/17 at 11:39 a.m., she confirmed she was Resident 4's CNA when he fell on 6/27/17. CNA C stated she was in the room directly across the hall from Resident 4's room when the fall occurred. CNA C stated she did not hear Resident 4's bed pad alarm beep at the time of the fall.
Review of a "Notice of Disciplinary Action" for CNA C, dated 6/27/17, indicated Resident 4 "did not have his alarm on, causing resident to have a fall/injury."
The facility's 8/2014 policy titled "Fall Prevention and Management Program" indicated, "The facility will implement a fall prevention and management program that supports providing an environment free from the hazards over which the facility has control."
Therefore, the facility failed to ensure the environment was free of accident hazards.
The above violation had a direct or immediate relationship to the health, safety, or security of the resident. |
| 040000064 |
TWILIGHT HAVEN |
040013483 |
A |
13-Sep-17 |
XWZD11 |
7267 |
F 223 483.12 Freedom from Abuse/Neglect and Exploitation
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.
(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.
On 4/24/17 an unannounced visit was made to the skilled nursing facility (SNF) to investigate Entity Reported Incident CA 00531444 regarding an allegation of resident abuse.
The facility failed to ensure Resident 1 was free from physical abuse when Certified Nursing Assistant (CNA) 1 stabbed Resident 1 more than once in the head with a ballpoint pen.
As a result of this failure, Resident 1 experienced pain, emotional distress, and an injury to her head requiring transport to the general acute care hospital (GACH) for evaluation and treatment.
Review of Resident 1?s clinical record titled, ?Record of Admission (record containing resident personal information)? indicated Resident 1 was 90 years old on the day of the incident and was admitted to the SNF on 4/17/17. The ?Record of Admission? indicated Resident 1 was admitted to the SNF for rehabilitation following surgery for a fractured (broken) hip and had diagnoses that included pain, hypertension (high blood pressure) and Alzheimer?s disease (progressive mental disorder with gradual loss of memory and development of personality changes).
On 4/24/17 at 12:40 p.m., during an interview, the Director of Nursing (DON) stated she received a text message from Licensed Nurse (LN) 1 on 4/19/17 at approximately 1:45 a.m. The DON stated LN 1 notified her CNA 1 had stabbed Resident 1 in the head with a pen. The DON stated she instructed LN 1 to call the police department (PD) to file a report against the CNA. The DON stated CNA 1 left the SNF later that night accompanied by police.
On 4/24/17 at 2:45 p.m., during an observation and concurrent interview, Resident 1 was sitting in her wheelchair in the activities room at the SNF. Resident 1?s hair was neatly combed and completely covered her scalp. Resident 1 did not respond to questions when asked about the altercation with CNA 1 on 4/19/17. Resident 1 did not interact with her surroundings or participate in the activity in progress.
On 8/10/17 at 10:15 a.m., during a telephone interview, LN 1 stated she was the charge nurse on the night shift on 4/19/17. LN 1 stated on 4/19/17 Resident 1 had resided at the facility for a few days and was at the SNF for rehabilitation following a broken hip and also had Alzheimer?s disease. LN 1 stated Resident 1 was very restless during the night on 4/19/17 and kept trying to climb out of bed. LN 1 stated she moved Resident 1 to a chair near the nurses? station and all staff took turns keeping an eye on her and reminding her not to get up out of the chair and attempt to walk by herself. LN 1 stated CNA 1 returned from her lunch break that night at 1:30 a.m. and she asked CNA 1 to sit with Resident 1 for safety reasons. LN 1 stated a few minutes later she heard Resident 1 yell, ?OW! OW! Why are you doing this to me? What did I do to deserve this?? LN 1 stated she looked up from where she was at the nurses? station and saw CNA 1 stabbing Resident 1, more than once, in the head with a ball point pen. LN 1
stated she immediately got up and separated the two and pushed CNA 1 back toward the cabinets at the nurses? station. LN 1 stated Resident 1 was sitting in her wheelchair with both hands held over the top of her head and there was blood seeping through her fingers. LN 1 stated she called for CNA 2 to help her and she placed a bandage over Resident 1?s head to stop the bleeding. LN 1 stated she asked CNA 1 why she stabbed Resident 1 in the head with a pen and CNA 1 told her Resident 1 had hit her on her face and she responded impulsively by stabbing Resident 1 in the head with her pen. LN 1 stated she informed CNA 1 she would call the police and then CNA 1 left the immediate area. LN 1 stated she notified the DON of the incident and called for an ambulance to transport Resident 1 to the GACH for evaluation of the bleeding head wound caused by CNA 1?s pen. LN 1 stated she also called the local police department (PD) and they responded within 10 minutes; located CNA 1 still sitting in the building and took CNA 1 with them when they left the building. LN 1 stated CNA 1 was an experienced CNA and had worked at the facility for almost one year. LN 1 stated CNA 1 should have responded differently to Resident 1?s confusion and restlessness; her behavior was not appropriate. LN 1 stated Resident 1 returned to the SNF from the GACH on 4/19/17 about 7 a.m., transported by her Responsible Party (RP) and did not have any wound dressings on her head.
Review of Resident 1?s GACH clinical record titled, ?Quick Registration? dated 4/19/17, indicated Resident 1 arrived at the GACH on 4/19/17 at 2:20 a.m. by ambulance.
Resident 1?s GACH clinical record titled, ?Physician Notes, Final Report? dated 4/19/17 at 2:42 a.m., indicated, ?This is a 90 y/o [year old] female BIBA [brought in by ambulance] s/p [status post ? meaning afterward] being stabbed in the head by a pencil [ball point pen]. Pt [patient] lives at a SNF and was stabbed with pen by a staff member at the facility. Pt states that she has some pain around the area. She states that she also has some slight neck pain?1 mm (millimeter, a measurement of length, one mm equals 0.04 inches) puncture wound to top of scalp?Diagnosis: Alleged assault?Superficial laceration of scalp.? The GACH ?Physician Notes, Final Report? indicated Resident 1 had undergone a ?Head Computed Tomography?(CT scan, specialized X-ray examination of the head) while at the GACH on 4/19/17 to screen for injury to Resident 1?s brain. The CT scan indicated, ?No acute [sudden and serious] intracranial [within the skull] abnormality.?
Review of facility administrative document titled, ?Resident Rights? dated 5/20/13 indicated, ?Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated?Patients shall have the right :?( 9) to be free from mental and physical abuse.?
Review of facility administrative document titled, ?Reporting Abuse? dated revised 2/13 indicated, ?Definitions?III. ?Abuse? means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.?
Therefore, the facility failed to ensure Resident 1 was free from physical abuse when CNA 1 stabbed Resident 1 more than once in the head with a ball point pen. As a result of this failure, Resident 1 expressed pain and distress during the assault and was transported to the GACH where she underwent a CT scan examination of her brain and treatment of a superficial wound to the head.
This violation placed Resident 1 in 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. |
| 120000328 |
The Rehabilitation Center of Bakersfield |
120013615 |
B |
16-Nov-17 |
Z7CH11 |
11580 |
F201 Reasons for Transfer/Discharge of Resident, CFR 483.15 (c) (1) (i) (ii)
(c) Transfer and discharge
(1) Facility requirements
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to ? 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to ? 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.
The facility failed to permit Patient 1 to remain in the facility after he removed some controlled medications from an unattended medication cart. Such failure resulted in Patient 1 being involuntarily discharged from the facility without medications to control his blood sugar or wound care supplies for his leg wounds. After his discharge, Patient 1 paid for a two-day motel stay, then went to a homeless shelter, and then was admitted to a general acute care hospital for high blood sugar and worsening of his leg wounds.
Patient 1 was a 51 year-old male, who was admitted to the facility on 5/8/17, and discharged on 6/3/17. His admitting diagnoses included cellulitis, muscle weakness, difficulty in walking, and diabetes mellitus.
(From the National Center for Biotechnology Information, U.S. National Library of Medicine, National Institute of Health, at www.ncbi.nlm.nih.gov:
"[C]ellulitis can develop if bacteria enter the skin through cuts or sores [and can] make your skin swell and become red, warm and tender. Left untreated, [cellulitis] sometimes can have serious complications. It is important to keep your skin protected while it heals. [Cellulitis] often arises in wounds or sores. Cellulitis affects the deeper layers of skin . . . . Severe cellulitis is a deeper pus-producing infection.
Diabetes is a disease in which the body does not control the amount of glucose (a type of sugar) in the blood . . . . This disease occurs when the body does not make enough insulin or does not use it the way it should [also known as diabetes mellitus].")
During his stay, Patient 1 received daily dressings to the wounds on both of his legs, antibiotics for an infection in his leg wounds infused directly into his veins, daily blood sugar monitoring, and insulin injections based upon his blood sugar test results.
During an interview with a staff person at the Kern County Public Guardian (KCPG), on 6/12/17, at 1:10 PM, he stated Patient 1 told him he had been "kicked out of the facility and insulted by the facility Administrator" on 6/3/17. The KCPG staff stated Patient 1 had to pay for a taxi-cab to a low-cost motel.
During a concurrent record review and interview with the Director of Nursing (DON), on 6/12/17, at 3:39 PM, the document titled "Face Sheet," indicated Patient 1 was admitted to the facility on 5/8/17, and then discharged on 6/3/17. The DON was unable to find any documentation in Patient 1's clinical records related to his discharge. The DON stated Patient 1 was discharged because he had a disagreement with the Administrator. He stated "He left in a cab, I don't know where."
The clinical record for Patient 1 was reviewed. The document titled "History and Physical Examination," dated 5/8/17, indicated Patient 1 had been admitted to the facility for "IV [in the vein] antibiotics" for two weeks to treat cellulitis in both of his legs. Patient 1's diagnosis was "BLE [bilateral lower extremity] cellulitis S/P [status post] debridement [surgical removal of dead skin] of ulcer [open wound]."
A physician order, dated 6/2/17, indicated Patient 1 was to have a blood sugar test three times a day, and to receive insulin (a medication that lowers blood glucose levels) injections if the blood sugar was too high. Another physician order, dated 5/16/17, indicated Patient 1 had daily treatment orders for a licensed nurse to cleanse the wounds on both his lower legs with a salt solution, and apply an ointment called "Santyl" [a prescription strength ointment that removes dead tissue from wounds so they can start to heal, and must be applied at least daily to be effective], then cover the wounds with a medicated dressing, and then wrap each lower leg with a gauze bandage and a "compression wrap."
During an interview with the Licensed Vocational Nurse (LVN) 1, on 7/6/17, at 3:17 PM, she stated the Administrator and DON spoke with Patient 1 on 6/3/17, and the Administrator told her "[Patient 1] has to go." LVN 1 stated Patient 1 was then asked to leave the facility because Patient 1 was responsible for missing pain medications - MS Contin (a strong prescription pain medicine that contains morphine, an opioid or narcotic).
During an interview with LVN 2, on 7/6/17, at 8:50 PM, she stated the Administrator had asked Patient 1 to leave the facility because the Administrator believed the patient stole his prescribed MS Contin from her medication cart. LVN 2 stated, that on 6/3/17, she hid the narcotic keys inside the Medication Administration Record binder that was on the top of the medication cart and walked away. LVN 2 stated "I guess the patients were watching me. That happened around 2-3 AM. A patient told me that some patients were around my medication cart." LVN 2 continued "I discovered [Patient 1's] Morphine bubble pack was missing at around 4 AM. It had 8-9 blue pills. [Patient 1] is alert and very aware of his medications. I went to speak with him about the missing medications and he just said okay. Around 5 AM or 5:30, another patient came and told me that [Patient 1] was out in the patio and he removed his cigarettes from his shirt pocket and some blue pills fell out of his pocket. I went to ask the patient but he denied it." LVN 2 stated, the Administrator and the DON came in to talk to the patient and a few hours later the DON told her that Patient 1 was leaving the facility. LVN 2 stated, "The DON and the Administrator helped him pack and I saw them escort him in his wheelchair out of the facility." LVN 2 was asked where the morphine (MS Contin) bubble pack was located, she stated, "It was in the locked narcotic box. I guess they were watching me and knew what keys I used. I know it was wrong. I left the keys in my MAR [Medication Administration Record] on top of the cart." LVN 2 stated the facility did not discipline her for leaving the medication keys unattended on top of the medication cart while being watched by some residents, and instead the facility took action against Patient 1 for taking the narcotic medications and asked him to leave.
During an interview with the Administrator, on 7/6/17, at 3:37 PM, he stated Patient 1 was being accused of taking morphine pain pills out of a facility medication cart without authorization. The Administrator stated Patient 1 became upset and left the facility. The Administrator stated "He left AMA [also known as a discharge Against Medical Advice]."
During a review of the clinical record with the Administrator and medical records personnel, they were unable to find documentation of Patient 1 leaving the facility AMA.
During an interview with Patient 1, on 8/3/17, at 2:46 PM, he stated that on the morning of 6/3/17, "[The Administrator] came out yelling: You're out of here." Patient 1 stated the Administrator became angry and had an argument with him and pushed him in his wheelchair to his room to gather his belongings. Patient 1 stated the Administrator asked a nurse to remove his PICC line (Peripherally Inserted Central Catheter - a flexible tube inserted into the vein, used to administer the antibiotics for his leg wound cellulitis), and pushed him in his wheelchair out the front door of the facility with no treatment supplies for his leg wounds, no supplies to check his blood sugar levels, and no insulin to treat his diabetes.
Patient 1 stated, "My leg ulcers [open wounds] were getting better when I was in the facility. I didn't want to leave, but the Administrator said that he would call the police if I didn't leave." Patient 1 stated he was on the side of the street and had to call and pay for a taxi-cab to take him to a low cost motel, because he had nowhere else to go. Patient 1 stated he did not have food to eat. He spent two days in the motel, and then to a homeless shelter. Patient 1 stated within days after he left the facility, his wounds became painful, red, and were draining large amount of fluids with a bad odor. Patient 1 stated he was re-admitted to a hospital on 6/10/17 for worsening condition of the wounds to both legs and high blood sugar levels.
The admission agreement for Patient 1, dated 5/11/17, indicated "Transfer and Discharges . . . If you are transferred or discharged against your wishes, we will provide transfer and discharge planning as required by law."
During a review of the clinical record for Patient 1 from his stay at a General Acute Care Hospital, the "Physician Assessment," dated 6/10/17, indicated he was admitted with "Admission Diagnosis 1) Bilat [bilateral, or both] LE [lower extremities] cellulitis and 2) abscesses [area full of pus, indicating infection], Bilat Ulcers with exudate [drainage] and pus. Pain management."
The document titled "Progressive Patient Interdisciplinary Care Plan/Communication," dated 6/10/17, at 6 PM, indicated Patient 1's blood glucose level was 424 (normal glucose range is between 70 - 110. Blood glucose levels over 400 can lead to many serious health problems, including coma and death).
The document titled "History and Physical," dated 6/10/17, indicated "[H]e has been having persistent pain, swelling, redness . . . and foul smelling discharge coming out of the ulcers in the bilateral legs." The document further indicated, "The patient will be admitted [the the hospital]. At this time he will be started on [two different IV] antibiotics . . . ."
Therefore, the facility failed to allow Patient 1 to appeal the decision to discharge him without notice, resulting in an unsafe discharge.
This violation has a direct relationship to the health, safety and security of Patient 1 and therefore is a B level citation.
Page 2 of 4 |
| 960000939 |
TERHUNE DIVISION |
960013557 |
B |
20-Oct-17 |
U4ZP11 |
6544 |
Title 22 76845
The securing of criminal records shall be in accordance with the provisions of Section 1265.5 of the Health and Safety Code.
1265.5 (a) (1) (f) (a)
(a)(1)?Prior to the initial licensure or renewal of a license of any person or persons to operate or manage an intermediate care facility/developmentally disabled habilitative, an intermediate care facility/developmentally disabled-nursing, an intermediate care facility/developmentally disabled-continuous nursing, or an intermediate care facility/developmentally disabled, other than an intermediate care facility/developmentally disabled operated by the state, that secures criminal record clearances for its employees through a method other than as specified in this section or upon the hiring of direct care staff by any of these facilities, the department shall secure from the Department of Justice criminal offender record information to determine whether the applicant, facility administrator or manager, any direct care staff, or any other adult living in the same location, has ever been convicted of a crime other than a minor traffic violation.
(f) Upon the employment of any person specified in subdivisions (a), and prior to any contract with clients or residents, the facility shall submit fingerprint cards to department for the purpose of obtaining a criminal record check.
On 9/12/17, the department received a complaint regarding Direct Care Staff (DCS 1) having a criminal conviction history and was denied providing direct care for clients in the Intermediate Care Facility (ICF) for the Developmentally Disabled (DD).
The facility's administrative staff failed to:
1. Place DCS 1 on a leave of absence when the Department of Justice (DOJ) denied DCS 1 from working and caring for six of six clients who reside in the facility due to criminal history. This failure had the potential for not ensuring the safety and well-being of all the clients and staff members.
On 9/12/17, at 3:50 pm, a Senior Health Facilities Evaluator Nurse called the facility and spoke to DCS 1. DCS 1 stated she is working at the facility and she had been working for the facility since 7/25/17.
On 9/12/17, at 3:53 pm, during a telephone interview with the facility's Qualified Intellectual Disability Professional (QIDP), she stated she received the denial letter for DCS 1 from the DOJ. The QIDP stated the facility's administrator approved for DCS 1 to continue to work until 9/27/17 (20 days), while obtaining the certificate of rehabilitation.
On 9/13/17, at 8:44 am, during a telephone interview with the facility's administrator, she stated DCS 1 did not have a certificate of rehabilitation and/or dismissal of the disqualifying conviction. The administrator stated it was a misunderstanding to let DCS 1 to continue working at the facility.
On 9/20/17, an unannounced visit was made to the facility to conduct a complaint investigation.
During an observation, on 9/20/17, at 8 am, the facility's population consisted of 6 clients who depend on staff for assistance with the basic activities of daily living. Clients 1, 2, 3 and 4 were at the facility waiting to be picked up to go to the day program. Clients 5, and 6 were already at the day program.
During a review of the clients' face sheet, it was indicated Client 1 had a diagnosis of mild intellectual disability (slower than typical in all developmental areas). Client 2 had a diagnosis of profound intellectual disability (significant developmental delays in all areas and incapable of self-care). Client 3 had a diagnosis of severe intellectual disability (considerable delays in development). Clients 4, 5 and 6 had a diagnosis of moderated intellectual disability (developmentally functions below chronological age and can learn elementary health and safety habits).
A review of the facility's staff schedule for the month of August and September 2017, indicated DCS 1 was working at the facility from 8/3/17 to 9/13/17.
During an interview with the facility's QIDP, on 9/20/17, at 8:35 am, she stated she was not sure when the corporate/main office received the denial letter for DCS 1. The QIDP stated the denial letter was mailed out to the main office on 8/31/17 and she received the denial letter from the main office on 9/7/17. The QIDP stated she took DCS 1 off the working schedule on 9/14/17, after she spoke to the Senior Health Facilities Evaluator Nurse from the Department.
A review of the denial letter, titled "Notice of Mandatory Denial of Criminal Record Clearance," dated 8/31/17, indicated the California Department of Public Health, Professional Certification Branch, Criminal Background Section has received criminal conviction offender information from the DOJ. Pursuant to Health and Safety Code Section 1265.5 (b) (1) the Department is required to deny criminal record clearance. This denial is effective immediately. The denial of criminal record clearance precludes the individual from owing, providing direct care and residing in ICF for the Developmentally Disabled clients. However, if the individual already has a certificate of rehabilitation and/or dismissal of the disqualifying conviction and submits this documentation to the Department within 20 days from the date of this letter, the individual may be allowed to continue employment at the employer discretion pending Department final review and decision regarding the individual's criminal record clearance. The letter also indicated as the individual is not granted criminal record clearance, this person's continued employment, ownership of, or residence on the facility's premises may result in a violation, pursuant to Health and Safety code Sections 1265 et seq.
A review of the facility's policy and procedure titled "Abuse and Neglect," indicated all employees who receive a denial for their fingerprints with the request for documentation of rehabilitation will be placed on a leave of absence during which time they will be responsible for obtaining a fingerprints clearance.
The facility?s administrative staff failed to place one Direct Care Staff (DCS 1) on a leave of absence when the Department of Justice (DOJ) denied DCS 1 from working and caring for six of six clients who reside in the facility due to criminal history. This failure had the potential for not ensuring the safety and well-being of all the clients and staff members.
The above violation had a direct relationship to the health, safety and security of clients. |
| 910000036 |
THE EARLWOOD |
910013406 |
A |
2-Aug-17 |
FKFQ11 |
14355 |
F323
CFR 483.25(h) 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.
Based on observation, interview and record reviews, the facility failed to ensure Resident A, who had dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbances, used a wheelchair for mobility, was unable to speak English, and exhibited elopement (when a person leaves an area without permission or notification which usually leads to placing that individual in a potentially dangerous situation) risk factors, as manifested by packing her belongings, roaming around the facility, sitting near the exit door, was kept safe and free from injury by:
1. Failure to closely monitor Resident A's whereabouts during a fire drill (a practice of the emergency procedures to be used in case of fire).
2. Failure to conduct an elopement risk assessment upon admission and after Resident A had an elopement attempt, in accordance to the facility's policy and procedure.
3. Failure to ensure residents determined to be at risk will receive appropriate interventions to reduce risk and minimize injury and to complete the Elopement Evaluation when Resident A exhibited signs of elopement risk between assessments.
Consequently, on March 13, 2017 at around 9 p.m., Resident A left the facility unnoticed and was missing after a fire drill. The resident was found on the same day at 9:50 p.m., outside in the vicinity of the facility and transported by emergency services (911) to a general acute care hospital (GACH) with multiple abrasions (superficial damage to the skin) to the face and lower extremities (legs) and a fracture (broken bone) to the right arm.
A review of Resident A's admission records indicated she was readmitted to the facility on December 15, 2015 with diagnoses that included difficulty walking, encephalopathy (brain disease, damage or malfunction) and dementia.
A review of a care plan, dated December 12, 2015 indicated Resident A was at risk for further falls due to impaired mobility, cognitive loss, dementia and having poor regards for safety. The interventions included assisting the resident in and out of the bed with extensive assistance; assisting with ambulation; providing verbal cues for safety when needed; providing the resident/caregiver with safe techniques; and providing a Spanish interpreter for needs and wants as needed. The care plan did not address the resident's risk factors of packing her belongings, roaming around the facility and sitting near exit door.
The Minimum Data Set (MDS- standardized assessment and care planning tool, dated March 2, 2017 indicated Resident A was able to understand and answered five of 15 questions from the brief interview for mental status. The MDS assessment further indicated the resident had no behaviors of wandering and required limited, one-person, physical assistance for bed mobility, transfers, walking in the room and locomotion on the unit. The resident had no functional limitation in the joints, and used a walker and wheelchair for mobility.
A review of the Progress Notes, dated March 13, 2017 at 9:20 p.m., indicated Resident A was noted to be missing. The facility activated a code pink (missing person) where the staff checked for the resident inside and outside of the building. According to the notes, the Assisted Living Facility (ALF) next to the facility and the GACH across the street from the facility were checked. At 9:40 p.m., the police was notified. At 9:50 p.m., the police called the facility stating the resident was found on the corner just past the facility and was taken via ambulance to a GACH.
A review of the investigation report, dated March 14, 2017, indicated Certified Nursing Assistant 2 (CNA 2) was asked if he/she saw Resident A. CNA 2 stated the resident was seen by the back door at around 6 p.m. to 6:30 p.m., with her clothes on the wheelchair. Resident A was brought back to the nursing station and CNA 2 stated Resident A spoke Spanish, and he could not understand her.
A Situation-Background-Assessment-Recommendation (SBAR) form, dated March 13, 2017, indicated Resident A eloped from the facility and was last seen by CNA 1 at 9 p.m., during a fire drill.
On March 16, 2017, at 10:45 a.m., during an interview, the administrator stated Resident A was alert with confusion and only spoke Spanish. The administrator stated she believed Resident A used the back door to leave the facility since her bedroom was near the back door and she was last seen in that vicinity. On the day she eloped (March 13, 2017), the resident had a large amount of family visiting her and she believed the resident may have been looking for her family after they left. The administrator further stated it was reported to her the resident was seen by multiple staff around 8 p.m., in the hallway sitting with other residents. When her assigned CNA (CNA 1) could not locate her, they initiated a code pink and searched inside and outside of the building, called the GACH across the street and notified the local police department. Approximately 10 minutes after speaking to the police, the local police called back to say the resident was at a GACH located in another part of city. The administrator stated apparently the resident had fallen from her wheelchair and was found on the ground on the corner down the street from the facility by someone who called 911. The administrator indicated Resident A had never exhibited indicators that would make her an elopement risk, nor had she ever attempted to leave the facility. She stated they only assess residents for elopement risk on admission, if there was a report of a history and/or attempts of elopement, and once the resident had indicators that would alert the staff about attempts or actually leaving the facility.
The administrator stated the building have alarms on all of the doors and there is receptionist present by the front door Monday thru Thursday from 8 a.m., until 7:30 p.m., Friday from 8 a.m., until 9:30 p.m., and Saturday thru Sunday from 8 a.m., until 4 p.m. The administrator stated the doors did not have a continuous sounding alarm making it unnoticeable since it was frequently used by staff, residents and visitors.
On March 16, 2017 at 11:15 a.m., during a tour of the facility it was confirmed when the front and back doors were opened, the alarm sounded loudly, only once, for approximately two seconds and then it stopped. The tour continued through the door to where the resident was believed to have eloped from. It was found the resident propelled herself through a parking lot, made a left and continued down a drive way that was approximately 30 yards in length, made a right at the end of the driveway and continued down the sidewalk for approximately 30 more yards when she most likely fell from her wheelchair when attempting to cross at the corner.
On March 16, 2017 at 11:30 a.m., Resident A was observed lying in bed on her back sleeping. There was an abrasion/bruise (forms because the soft tissues of your body have been bumped) to her forehead and to the left side of her nose. A sling was noted on her right upper extremity, the rest of her body was covered by a blanket and not visible for observation.
On March 16, 2017, at 11:54 a.m., during a subsequent interview, the administrator stated the facility contracts with a company to conduct the facility's fire drills and the evening when Resident A eloped, the fire consultant conducted a fire drill at the facility. The administrator indicated the staff may have been preoccupied with the fire drill, which possibly allowed the resident to leave the facility unnoticed.
On March 16, 2017, at 12:35 p.m., during an interview, Registered Nurse (RN 1), the Director of Staff Development (DSD) stated she gave a recent elopement in-service that included the types of indicators to look for in residents who may be trying to leave the facility. The DSD stated some of the indicators include statements from the residents saying they want to and/or are going home, moving toward and always congregating around the doors and packing their things. When those indicators occurred the staff was instructed to report to their charge nurse and be more observant of the resident's behavior and whereabouts.
A review of the Elopement In-service dated February 28, 2017, disclosed no documentation reflecting the elopement risk indicators. Additionally, CNA1 was not on the list of staff who attended the In-service.
On March 16, 2017 at 12:55 p.m., during an interview, the MDS nurse stated she was at the facility when Resident A eloped. She stated she was walking out the front door about 8:45 p.m., when the fire consultant came to the facility. She walked back into the facility with him and assisted with the fire drill by activating the fire alarm. She stated most of the staff was present at the fire drill, which lasted approximately 15 minutes. She then walked out of the building with the fire consultant around 9:05 p.m. When she returned at approximately 9:25 p.m., staff reported to her the resident was missing. She stated it was a definite possibility the resident eloped from the facility when staff was distracted with the fire drill.
On March 16, 2017, at 4:25 p.m., during an interview CNA 1 stated he brought Resident A to the dining room at approximately 5 p.m., for dinner. The next time he saw her was at approximately 7:30 p.m. At that time she had all of her belongings from her drawers and closet including her diapers packed and sitting in her wheelchair. Resident 1 was behind the wheelchair pushing it walking back and forth in front of her bedroom which made him think she was planning on leaving. CNA 1 redirected her back to her room at around 8 p.m., then placed the resident?s clothing in the closet and left her sitting on her bed. CNA 1 stated the resident was speaking in Spanish but he could not understand what she was saying. CNA 1 then went on his break from 8 p.m., - 8:30 p.m., and when he returned to Resident A's room at approximately 9:20 p.m., she was not there.
A review of the Facility's Floor Plan indicated Resident A's room was in close proximity to the facility's back door. There were two resident rooms, DON's office, a restroom and another office that separated the resident's room from the back door.
A review of the Emergency Documentation from the GACH where Resident A was transferred after the elopement and fall incident, dated March 13, 2017 indicated the resident was alert, awake and oriented to person. She was brought in by an ambulance after a fall out of her wheelchair while going down a driveway in the street. She had a laceration to her forehead with pain to her right shoulder and ankles.
An X-ray report dated March 13, 2017 indicated a comminuted fracture (when a bone is broken into several parts) through the right humeral neck (the bone of the upper arm, extending from shoulder to elbow) with medial displacement (fractures resulting in abnormal positions of the bone).
A review of the readmission Nursing Assessment form dated March 15, 2017 showed the following:
1. Abrasions to nasal area
2. Abrasions to the right and left knees
3. Discoloration to right periorbital (the bony part of the skull that houses and protects the eyeball, the eye socket) extending to her nasal area and cheeks
4. Discoloration to left shin (the front of the leg below the knee) and left hand
5. Swollen and bruised right arm extending to the back, elbow and armpit.
A review of the facility's policy and procedures titled, "Elopement of Patient"
dated May 15, 2014 indicated patients will be evaluated for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. To complete the Elopement Evaluation (both electronic and non-electronic) if a patient exhibits signs of elopement risk between routine assessment/evaluation.
There was no documented evidence the facility conducted an elopement risk assessment upon admission and when Resident A exhibited elopement behaviors.
he facility failed to ensure Resident A, who had dementia (a group of thinking and social symptoms that interferes with daily functioning) with behavioral disturbances, used a wheelchair for mobility, was unable to speak English, and exhibited elopement (when a person leaves an area without permission or notification which usually leads to placing that individual in a potentially dangerous situation) risk factors, as manifested by packing her belongings, roaming around the facility, sitting near the exit door, was kept safe and free from injury by:
1. Failure to closely monitor Resident A's whereabouts during a fire drill (a practice of the emergency procedures to be used in case of fire).
2. Failure to conduct an elopement risk assessment upon admission and after Resident A had an elopement attempt, in accordance to the facility's policy and procedure.
3. Failure to ensure residents determined to be at risk will receive appropriate interventions to reduce risk and minimize injury and to complete the Elopement Evaluation when Resident A exhibited signs of elopement risk between assessments.
Consequently, on March 13, 2017 at around 9 p.m., Resident A left the facility unnoticed and was missing after a fire drill. The resident was found on the same day at 9:50 p.m., outside in the vicinity of the facility and transported by emergency services (911) to a general acute care hospital (GACH) with multiple abrasions (superficial damage to the skin) to the face and lower extremities (legs) and a fracture (broken bone) to the right arm.
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. |
| 950000013 |
THE ROWLAND |
950013587 |
B |
30-Oct-17 |
IN0511 |
5356 |
F309 ? 42 CFR? 483.24 Quality of life
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
? 483.25 Quality of care
Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
F514 ? 42 CFR ?483.70(i) Medical records.
(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are?
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized
(5) The medical record must contain?
(i) Sufficient information to identify the resident;
(ii) A record of the resident?s assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician?s, nurse?s, and other licensed professional?s progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under
?483.50.
On 6/30/17 at 1:45 p.m., an unannounced visit was made to the facility to investigate a complaint regarding residents developing rashes.
Based on observation, interview and record review, the facility failed to provide Resident 2 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, and recognized standards of practice to meet the needs of the resident, including but not limited to:
1. Failure to assess accurately the current condition of Resident 2?s skin for presence of rashes.
2. Failure to document Resident 2?s current skin condition.
Resident 2 was tested positive for scabies by the hospital on the day of the resident's transfer to the hospital. There was no documentation from the facility prior to the transfer to the hospital that the resident had a rash.
These deficient practices had the potential for Resident 2 to experience itchiness without relief and for the spread the infectious and itchy rash to other residents.
During an interview, on 6/30/17 at 2 p.m., the director of nursing (DON) stated a Public Health Nurse (PHN) visited the facility this morning. The DON stated they both toured the facility to check residents who had a rash. The DON stated after the tour, there were seven residents identified with rashes, which included Resident 2.
A review of Resident 2's Face Sheet (admission record) indicated Resident 2 was admitted to the facility on 5/28/14, transferred to general acute care hospital (GACH) 6/9/17 to 6/14/17 and re-admitted to the facility on 6/14/17 with diagnoses that included peritonitis (an inflammation of the membrane that lines your inner abdominal wall), diabetes mellitus (a metabolism disorder that affects the body's ability to use blood sugar), and muscle weakness.
A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 12/3/16, indicated the resident was unable to complete a brief interview for mental status. Resident 2's functional status indicated the resident needed extensive assist (resident involved in activity; staff provide weight bearing support) on bed mobility and transfer.
A review of Resident 2's facility's transfer sheet to GACH, dated 6/9/17, indicated the facility conducted a body check on the resident. There was no documentation of Resident 2 having rashes.
A review of Resident 2's GACH record titled, "Consultation," dated 6/9/17, an infectious disease doctor indicated the resident as having possible scabies.
A review of Resident 2's GACH record titled, "Miscellaneous Culture," dated 6/10/17, indicated scabies was present on the resident.
During an interview, on 6/30/17 at 2:20 p.m., a licensed nurse/treatment nurse (TN 1) stated Resident 2 was tested positive for scabies while at the acute care hospital and the resident was treated once at the hospital. TN 1 stated the resident's second treatment for scabies was given at the facility.
During an observation, on 6/30/17 at 2:50 p.m., Resident 2 had rashes on the lower abdomen and left outer side of his hand.
The facility failed to provide 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, and recognized standards of practice to meet the needs of the resident, including but not limited to:
1. Failure to assess accurately the current condition of Resident 2?s skin for presence of rashes.
2. Failure to document Resident 2?s current skin condition.
These deficient practices had the potential for Resident 2 to experience itchiness without relief and for the spread the infectious and itchy rash to other residents.
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 2. |
| 950000013 |
THE ROWLAND |
950013588 |
B |
30-Oct-17 |
IN0511 |
7203 |
F309 ? 42 CFR? 483.24 Quality of life
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
? 483.25 Quality of care
Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
F514 ? 42 CFR ?483.70(i) Medical records.
(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are?
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized
(5) The medical record must contain?
(i) Sufficient information to identify the resident;
(ii) A record of the resident?s assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician?s, nurse?s, and other licensed professional?s progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under
?483.50.
On 6/30/17 at 1:45 p.m., an unannounced visit was made to the facility to investigate a complaint regarding residents developing rashes.
Based on observation, interview and record review, the facility failed to provide Resident 3 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, and recognized standards of practice to meet the needs of the resident, including but not limited to:
1. Failure to assess accurately the current condition of Resident 3?s skin for presence of rashes.
2. Failure to document Resident 3?s current skin condition on the General Nurse's Observation (a weekly assessment form), under the skin condition section, and on the form ?Progress Notes by Resident-by Note Type."
Resident 3, had self-inflicted wounds from scratching and had an unresolved generalized rash since 10/6/16. The licensed nurse was not assessing the skin for presence of rash. Resident 3 stated he could not sleep because of the itchiness.
These deficient practices resulted in Resident 3 experiencing itchiness without relief and had the potential to spread the infectious and itchy rash to other residents.
During an interview, on 6/30/17 at 2 p.m., the director of nursing (DON) stated a Public Health Nurse (PHN) visited the facility this morning. The DON stated they both toured the facility to check residents who had a rash. The DON stated after the tour, there were seven residents identified with rashes, which included Resident 3.
During an observation, on 6/30/17 at 3:25 p.m., Resident 3 was in his bed awake, restless, scratching both arms and body. Resident 3 had red bumps in front and back trunk, head, legs and finger webs. Resident 3 stated he could not sleep because of the itchiness.
A review of Resident 3's Face Sheet (admission record) indicated Resident 3 was admitted to the facility on 7/11/14 and re-admitted on 2/11/16 with diagnoses that included dementia (a persistent mental process disorder), diabetes mellitus (DM-a metabolism disorder that affects the body's ability to use blood sugar), and hypertension (HTN-high blood pressure).
A review of Resident 3's care plan, dated 10/6/16 and 3/31/17, indicated Resident 3 had consistent generalized rash that was not resolved.
A review of Resident 3's physician order sheet indicated to administer the following medications to the resident:
a. Benadryl Cream (an anti-itch medicine) to general rash, which was ordered on 10/6/16 for dermatitis (a skin infection) and discontinued on 10/13/16.
b. Triamcinolone Cream to itchy rash as needed, which was ordered on 10/13/16 up to 2/13/17 and renewed on 3/31/17 for general rash, to apply daily for 40 days (ending 5/10/17).
c. Benadryl 25 milligram (mg) by mouth twice a day for 14 days for itching, which was ordered 10/28/16 (ending 11/10/16).
d. Cetirizine (an anti-allergy medicine) 10 mg by mouth at bedtime, which was ordered on 1/30/17.
e. Lidex Cream (a steroid medicine for skin itchiness) to apply to generalized rash twice per day, which was ordered on 2/13/17 and discontinued on 2/27/17.
f. Atarax (a medication used to treat anxiety disorders and allergic skin condition) 25 mg by mouth twice a day for 30 days for pruritus (itchiness), which was ordered 5/18/17. The last dose was administered on 6/16/17.
A review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/2/17, indicated Resident 3's cognition was moderately impaired. Section C, Skin Condition, of the MDS indicated Resident 3 had no skin issues present.
A review of Resident 3's General Nurse Observation, a weekly assessment, dated 6/17/17 and 6/24/17, under Skin Condition, indicated Resident 3's skin was clear.
A review of Resident 3's record titled, "Multi Wound Chart Detail," an assessment from a wound physician, dated 6/19/17, indicated Resident 3 had chronic dermatitis, had a self-inflicted wound from scratching, and was on Atarax.
During an interview, on 6/30/17 at 4:40 p.m., the DON stated the licensed nurses do not document the presence of skin rash on the weekly assessment form, General Nurse's Observation. The DON stated the presence of rashes is documented on "Progress Notes by Resident-by Note Type." Resident 3?s progress notes, "Progress Notes by Resident-by Note Type," from 6/17/17 to 6/30/17 were reviewed with the DON and there was no documentation that Resident 3 had rashes.
A review of Resident 3's physician's order, dated 6/30/17 at 5 p.m., indicated Resident 3 was placed on contact isolation, had his skin scraped for scabies (skin testing for scabies mite) and to apply Elimite cream. The physician order was made as a result of the visit from the PHN on 6/30/17 in the morning.
The facility failed to provide 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, and recognized standards of practice to meet the needs of the resident, including but not limited to:
1. Failure to assess accurately the current condition of Resident 3?s skin for presence of rashes.
2. Failure to document Resident 3?s current skin condition on the General Nurse's Observation (a weekly assessment form), under the skin condition section, and on the form ?Progress Notes by Resident-by Note Type."
These deficient practices resulted in Resident 3 experiencing itchiness without relief and had the potential to spread the infectious and itchy rash to other residents.
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 3. |
| 950000013 |
THE ROWLAND |
950013581 |
B |
30-Oct-17 |
IN0511 |
9412 |
F309 ? 42 CFR? 483.24 Quality of life
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident?s comprehensive assessment and plan of care.
? 483.25 Quality of care
Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices, including but not limited to the following:
F425 ? 42 CFR ?483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in ?483.70(g). 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;
F514 ? 42 CFR ?483.70(i) Medical records.
(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are?
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized
(5) The medical record must contain?
(i) Sufficient information to identify the resident;
(ii) A record of the resident?s assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician?s, nurse?s, and other licensed professional?s progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under
?483.50.
On 6/30/17 at 1:45 p.m., an unannounced visit was made to the facility to investigate a complaint regarding residents developing rashes.
Based on observation, interview and record review, the facility failed to provide necessary care and services to Resident 1to attain or maintain the highest practicable physical, mental, psychosocial well-being, in accordance with his comprehensive assessment and plan of care, and recognized standards of practice to meet the needs of the resident, including but not limited to:
1. Failure to assess accurately the current condition of Resident 1? skin for presence of rashes.
2. Failure to document Resident 1?s current skin condition on the General Nurse's Observation (a weekly assessment form), under the skin condition section, and on the form ?Progress Notes by Resident-by Note Type."
3. Failure to monitor and document the date, time, and reason Resident 1 was self-administering an anti-itch medicated cream.
Resident 1 was started on an anti-itch medicated cream on 1/25/17 and the resident was allowed to self-administer the anti-itch cream from 4/6/17 to 5/15/17 as ordered. The licensed nurse was not monitoring the number of times the resident was self-administering the cream and not assessing the skin for presence of rash. Resident 1 stated he could not sleep and the nurses had been putting cream on his skin without relief.
These deficient practices resulted in Resident 1 experiencing itchiness without relief and had the potential to spread the infectious and itchy rash to other residents.
During an interview, on 6/30/17 at 2 p.m., the director of nursing (DON) stated a Public Health Nurse (PHN) visited the facility this morning. The DON stated they both toured the facility to check residents who had a rash. The DON stated after the tour, there were seven residents identified with rashes, which included Resident 1.
During an observation and interview, on 6/30/2017 at 2:40 p.m., Resident 1 was observed sitting in a wheelchair inside his room and scratching his arms. Resident 1 was observed with red bumps on his upper front body, arms and legs. Resident 1 stated he could not recall the onset of his rashes, but it had been awhile. Resident 1 stated his itchiness started when he was in the same room with Resident 3 but Resident 1 was unable to recall the time period he shared a room with Resident 3. Resident 1 stated he could not sleep and the nurses had been putting cream on his skin without relief.
During an interview, on 6/30/17 at 3:05 p.m., the licensed vocational nurse (LVN) 1 stated Resident 1 had the rash about six months now. LVN 1 stated Resident 1 had been itching and scratching.
A review of Resident 1's Face Sheet (admission record) indicated Resident 1 was re-admitted to the facility on 3/16/16 with diagnoses that included rhabdomyolysis (damage of the skeletal muscle), diabetes mellitus (DM-a metabolism disorder that affects the body's ability to use blood sugar), and hypertension (HTN-high blood pressure).
A review of Resident 1's Minimum Data Set (MDS-clinical assessment tool), dated 3/13/17, indicated Resident 1's cognition was intact and the resident needed limited assistance (resident highly involved in activity; staff provide guided-maneuvering of limbs or other non-weight bearing assistance) with bed mobility, transfer, and room ambulation.
A review of Resident 1's record titled, "Resident Care Plan," dated 1/25/17 indicated the resident had generalized itchy rash due to contact dermatitis (inflamed skin).
A review of Resident 1's physician order sheet and Medication and Electronic Treatment Administration Record (ETAR) indicated to administer the following medications to the resident:
a. Triamcinolone cream for forty days (an anti-itch cream) for generalized rash, which was started on 1/25/17.
b. Clotrimazole Bethamethasone cream (an antifungal medicine) for generalized rash, which was started on 1/31/17.
c. Mometasone ointment (a steroidal medicine that reduces skin inflammation) for itchy rash, which was started on 2/28/17 then renewed on 4/6/17 for 40 days (ending on 5/16/17), may allow the resident to apply Mometasone ointment to generalized rash at night per resident request. There was no Mometasone order from 5/16/17 to 6/30/17.
A review of Resident 1's Medication Self Administration evaluation, dated 4/6/17, indicated Resident 1 could self-administer Mometasone. There was no evidence on the ETAR that the licensed nurses were monitoring and documenting the number of times the resident was self-administering the Mometasone.
A review of Resident 1's General Nurse's Observation (a weekly assessment), under skin condition, dated 6/17/17 and 6/24/17, indicated Resident 1's skin was clear.
During an interview, on 6/30/17 at 4:40 p.m., the DON stated the licensed nurses do not document the presence of skin rash on the weekly assessment form, General Nurse's Observation. The DON stated the presence of rashes is documented on "Progress Notes by Resident-by Note Type." Resident 1?s progress notes, "Progress Notes by Resident-by Note Type," from 6/17/17 to 6/30/17 were reviewed with the DON and there was no documentation that Resident 1 had rashes.
A review of the Resident 1's physician's order, dated 6/30/17 at 5 p.m., indicated to place Resident 1 on contact isolation (a standard measure to prevent the spread of infection) and to apply on the resident an Elimite cream (a medication used to treat scabies). The physician also ordered Mometasone ointment as needed and moisturizer for skin maintenance. The physician order was made as a result of the visit from the PHN on 6/30/17 in the morning.
A review of Resident 1's ETAR, dated 6/30/17, Elimite was given.
During an observation and interview, on 7/3/17 at 3:30 p.m., Resident 1 was observed with red bumps on his upper front body and arms. He stated he had less itching compared to a couple of days ago. Resident 1 verbalized his anger towards his exposure in the past to Resident 3, who had rashes when they were in the same room from 8/17/16 to 1/4/17.
The facility failed to implement infection control measures and provide 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, and recognized standards of practice to meet the needs of the resident, including but not limited to:
1. Failure to assess accurately the current condition of Resident 1? skin for presence of rashes.
2. Failure to document Resident 1?s current skin condition on the General Nurse's Observation (a weekly assessment form), under the skin condition section, and on the form ?Progress Notes by Resident-by Note Type."
3. Failure to monitor and document the date, time, and reason Resident 1 was self-administering an anti-itch medicated cream.
These deficient practices resulted in Resident 1 experiencing itchiness without relief and had the potential to spread the infectious and itchy rash to other residents.
The above violations had a direct or immediate relationship to the health, safety, or security of Resident 1. |