| 100000002 |
University Post-Acute Rehab |
030009682 |
B |
27-Dec-12 |
D47L11 |
3144 |
California Health & Safety Code - 1418.91 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours.(b) A failure to comply with the requirements of this section shall be a class "B" violation. A federal recertification survey was conducted at the facility 10/29/12 through 11/1/12. On 10/30/12, facility staff produced a black notebook with the title "Social Services Communication Log."On the line dated 3/2/12 and beside the name of Resident 1, the following was documented: "Accuses staff/others of slapping her ..." The Department determined that the facility failed to report the alleged abuse or suspected abuse of a resident to the Department within 24 hours. Resident 1 was admitted to the facility on 1/25/12 with the diagnosis of Altered Mental Status due to a urinary tract infection, sepsis (an infection in the blood), severe dementia, muscle weakness and difficulty in walking. In an interview on 10/31/12 at 9:40 a.m., the Administrator stated he was first made aware of the allegation of abuse noted in the Social Service log yesterday, 10/30/12. "It was not brought to my attention in a timely manner." In a statement dated 10/31/12, the Director of Staff Development indicated, "In the morning of March 2, 2012 I was doing rounds and LN [Licensed Nurse] reports to me that resident reports that some staff slapped ... her. I briefly stopped by to see resident and spoke to her ... I did not notice any visible signs of redness on her face or arms and did not show any fear while I was speaking to her. At this time I feel I did not suspect any abuse due to her severe dementia, so I put an entry in [the] SSD [Social Services Directors] binder ..." In a letter to the Department dated 11/1/12, the Administrator confirmed, "On 10/30/12, I was notified regarding an allegation of abuse that occurred on 3/2/12. We started an investigation regarding the allegation of abuse, which was concluded on 10/31/12." The facility's Administrative Manual for Elder/Dependent Adult Abuse (revised 7/18/05), indicated, "It is the responsibility of the facility's employees ... to immediately report any incident or suspected incident of neglect or resident abuse ... to the facility administrator ... Each employee is a mandated reporter and has a duty as an individual, to immediately report any actual/known, alleged, suspected incident of physical abuse ... to administrator of the facility ... immediately or as soon as possible but not to exceed 24 hours after the discovery of the incident ... The facility will report all "alleged", known, or suspected incidents of physical abuse ... to the state survey and certification agency ... immediately or as soon as possible but no later than within 24 hours of such knowledge." The Department determined that the facility failed to report the alleged abuse or suspected abuse of a resident to the Department within 24 hours. These violations had a direct or immediate relationship to the health, safety, or security of long-term care facility patients or residents |
| 050000468 |
UCP/SCF HILLCREST ICF/DD-N |
050007674 |
B |
11-Apr-12 |
56PP11 |
4373 |
Welfare and Institutions Code 4502(h) 4502. Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having a developmental disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to the following:(h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse or neglect. The facility did not comply with the above statute when it failed to ensure that a developmentally disabled client was free from harm and not subjected to abuse by a staff member. On September 18, 2010, Staff 1 heard Client A yelling "stop it, leave me alone," and when she entered Client A's bedroom, she found Licensed Nurse 1 (LN1) with his arms around the client and his left hand down the front of Client A's pants.Client A was admitted to the facility on October 20, 2008, with diagnoses including moderate mental retardation and epilepsy. A profile of the client's strengths and needs dated March 26, 2010, noted that Client A is able express herself verbally, requires limited assistance with dressing, and can eat, brush her teeth, brush her hair, and wash her hands and face, independently. The profile also noted that Client A is able to ambulate independently for short distances, and is incontinent and wears briefs.Staff 1 was interviewed on October 1, 2010, and said that on the morning of September 18, 2010, she answered Client A's call light, went into her bedroom, changed the client's briefs, and found a poker chip inside the briefs. Staff 1 indicated there were also poker chips all over the client's bed and on the floor, and when she asked Client A about the poker chips, she said that LN1 was throwing them at her.Staff 1 said that a few hours later, she heard Client A yelling "stop it, leave me alone," and when she entered the client's bedroom, LN1 was standing behind Client A, with his arms around the client and his left down the front of her pants. Staff 1 stated that she asked LN1 what he was doing, and he removed his hand from the client's pants very quickly and said, "she may be wet." Staff 1 said that she asked LN1 to leave the room, and after he left, Client A started to cry and stated, "he always bothers me." Staff 1 also stated that male staff are not allowed to work alone with female clients or to be in the bedroom with a female client unless a female staff is present.On September 18, 2010, the facility also became aware of another incident involving LN1 and Client A that was witnessed by Staff 3. Staff 3 was interviewed on October 1, 2010, and stated that two weeks prior to the incident on September 18, 2010, she went into Client A's room to change her briefs, and saw LN1 touching the client's breasts.Staff 3 indicated LN1 was standing behind Client A with his arms around the client, and his hands spread over and touching the client's breasts. Staff 3 stated that she felt very uncomfortable, did not know what to do, and that she backed out of the room quietly, waited one minute, then came back into the room. She indicated she told LN1 she was going to change the client as she entered the room, and he left the room and closed the door. After the incident on September 18, 2010, she told Staff 2 what she saw two weeks prior, and asked Staff 2 to report what she observed. Client A was interviewed on October 4, 2010. Client A said that LN1 was rude, demonstrated that LN1 put his hand over her mouth and nose, and stated that she did not like it. When she was asked if LN1 touched her anywhere else, Client A lowered her head, and did not reply. When she was asked about the poker chip Staff 1 found in her briefs, Client 1 again lowered her head and said that LN1 put the chip in her pants.The facility violated the above statute by failing to ensure that Client A was free from harm and not subjected to abuse by a staff member.The failure had a direct or immediate relationship to the health, safety and security of the clients. |
| 050000468 |
UCP/SCF HILLCREST ICF/DD-N |
050009214 |
B |
11-Apr-12 |
56PP11 |
3446 |
Welfare and Institutions Code 4502(h)4502. Persons with developmental disabilities have the same legal rights and responsibilities guaranteed all other individuals by the United States Constitution and laws and the Constitution and laws of the State of California. No otherwise qualified person by reason of having 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 did not comply with the above statute when it failed to ensure that a developmentally disabled client was free from harm and not subjected to abuse by a staff member. On September 18, 2010, Licensed Nurse 1 (LN1) handled Client B roughly, spoke to him in a threatening manner, and left the dependent client alone in his room without access to his call light.Client B was admitted to the facility on June 12, 1995, with diagnoses including cerebral palsy, spastic quadriplegia, osteoporosis, anemia, gastro-esophageal reflux disease and anxiety. A profile of the client's strengths and needs dated May 10, 2010, noted that Client B requires maximum assistance to get dressed, brush his teeth, brush his hair, and wash his hands and face. According to the profile, Client B is able to translocate in a motorized wheelchair, is very social, and uses vocalizations, gestures and a communication board to communicate with others. The profile also noted that Client B is fed by staff, is able to identify the foods he likes and dislikes, and to make his preferences known. Staff 2 was interviewed on October 1, 2010, and indicated that during lunch on September 18, 2010, Client B did not want to eat. She observed LN 1 grab the client's chin, hold it up, place his face close to Client B's face, and threaten Client B by yelling , "this is bullshit-if you don't eat, we're putting a G-tube in you." (Gastric feeding tube surgically inserted through the abdominal wall into the stomach). Staff 2 indicated that LN1 appeared angry. Staff 2 said that after lunch, she heard Client B screaming and went into his room. She indicated that the client's bed was in the middle of the room, the bed was in an upright position, the client was slumped over, the side rails on the bed were down, and the client did not have access to his call light. Staff 2 stated that Client B told her that he was afraid and said that LN1 had done this.Client B was interviewed on October 4, 2010. When he was asked if he had problems with any of the staff, he used his communication board and indicated he had problems with LN1. During the interview, Client B verified that LN1 yelled at him and grabbed his chin when he was in the dining room, and indicated he did not like it. He also verified that LN1 was the person who left him in his room without a call light, and indicated he was glad that LN1 did not work at the facility anymore. The facility violated the above statute by failing to ensure that Client B was free from harm and not subjected to abuse by a staff member.The facility's failure had a direct or immediate relationship to the health, safety and security of the client. |
| 060000784 |
UCP/SCF BUENA PARK |
060013458 |
B |
30-Aug-17 |
O39M11 |
11042 |
W127 - 483.420(a)(5)
The facility must ensure that clients are not subjected to physical, verbal, sexual, or psychological abuse or punishment.
Client 5 was admitted to the facility on XXXXXXX16, with diagnoses including cerebral palsy (a disorder of movement, muscle tone or posture caused by an insult to the immature, developing brain, most often before birth) and spasticity (a condition in which certain muscles are continuously contracted causing stiffness or tightness of the muscles and involuntary muscle spasms or sudden movements can interfere with normal movement, speech and gait.) Client 5 was nonambulatory, mobile via electric wheelchair, nonweight bearing, and dependent on facility staff for all transfers.
On 7/17/17 at 1700 hours, an interview was conducted with Client 5. Client 5 stated he had fallen twice, four months apart, in the past seven months since he was admitted to the facility. The client stated the two times he had fallen out of his wheelchair was when he was being transferred via the Hoyer lift (an assistive device that allows patients to be transferred between a bed and a chair or other similar resting places, using hydraulic power.) The client stated he had bruised and hurt his left thumb the first time he fell, but he did not see the doctor. And the second time he fell, he had hurt his nose and gone to the emergency room. Client 5 stated his father had requested for two staff to perform all transfers, but that only happened for 72 hours. Client 5 stated only one staff member was completing his transfers at the current time.
On 7/18/17 at 0832 hours, an interview and concurrent facility record review was conducted with the Registered Nurse (RN). When asked if Client 5 had fallen twice since his admission to the facility (XXXXXXX16), the RN verified he had fallen on 2/10 and 6/12/17. The RN provided two incident reports dated 2/10 and 6/12/17.
Review of the Facility Incident Report dated 2/10/17, showed as Direct Care Staff (DCS) 16 was transferring Client 5 to his wheelchair with the mechanical lift, DCS 16 moved away from the client to move the lift, and Client 5 slid off of his chair, bumped his head, and bruised his thumb. There was no documented evidence on the incident report to show DCS 16 was transferring Client 5 with a second staff.
Review of the Facility Incident Report dated 6/12/17, showed that during an assisted transfer into his wheelchair, Client 5 slipped out of his chair hitting his nose and area above his left eyebrow. Client 5 received superficial abrasions on the bridge of his nose and above his left eyebrow and was transported to the emergency room for evaluation.
Review of the Client Incident Report dated 6/12/17, showed Client 5 fell when DCS 8 was putting Client 5 back in his wheelchair with the mechanical lift. The report showed when DCS 8 was unlatching the client from the mechanical lift, she moved the lift, and as she was holding the client back in his wheelchair, the client fell to the side and scraped his nose on the edge of the door. There was no documented evidence on the incident report to show DCS 8 was transferring Client 5 with a second staff.
Review of the Physical Therapist (PT)'s initial assessment dated 1/15/17, showed Client 5's lower extremities were in extreme flexion (a condition in which the leg is bent at the knee joint decreasing the angle between the bones of the leg at the joint), his left wrist was fused, he had poor protective reactions, he was only able to extend his right arm with purpose, he was unable to stand or bear weight, was dependent for transfers, and he used a Hoyer lift. The PT's assessment did not indicate which type of mechanical lift or sling Client 5 should use.
Review of the Occupational Therapist (OT) report dated 12/19/16, showed Client 5's left wrist was surgically fused, he had severe spasticity in his left arm, poor coordination with his left arm, required total assistance for functional transfers, and used a mechanical lift for transfers. The OT's report did not indicate which type of mechanical lift or sling Client 5 should use.
On 7/18/17 at 1355 hours, an interview was conducted with the Qualified Intellectual Disabilities Professional (QIDP) and Assistant Administrator. When the QIDP was asked how Client 5 fell on 6/12/17, he stated DCS 8 and 3 were transferring Client 5. However, another client had an emergency and DCS 3 went to help the other client, leaving DCS 8 with Client 5. This was when Client 5 fell while being put back into his wheelchair by DCS 8. The QIDP stated Client 5 was already in the "up" position when DCS 3 left DCS 8 alone with Client 5 to complete the transfer. The QIDP stated it was the facility's policy to always use two staff for transfers.
During a later interview with the QIDP on 7/18/17 at 1422 hours, the QIDP was asked for the facility's Policy and Procedure (P&P) regarding falls and the QIDP stated the facility did not have a P&P regarding falls.
On 7/19/17 at 0826 hours, an interview and concurrent mechanical lift demonstration was conducted with DCS 8 and 3. DCS 8 explained and demonstrated how she transferred Client 5 back into his wheelchair on 6/12/17, when he fell. DCS 8 stated she used the Power Stander lift with the StandUp sling to transfer Client 5. DCS 8 stated she spread the lift's legs, positioned the lift in front of the client's wheelchair, positioned Client 5's buttocks over the front edge of the seat, lowered the client into the wheelchair, removed the ropes from the lift and removed the sling, placed her hand on the client's stomach while pushing the lift away with her foot, and at that time the client slid to his left side over his wheelchair's armrest, and fell on the floor. DCS 8 stated Client 5 landed on his left shoulder, but he hit his nose on the door jamb on the way down. DCS 3 stated she was assisting DCS 8 with the transfer, but she left to help another client before the transfer was complete.
Review of the Power Stander Manual dated 8/20/07, showed in part: when lowering the client with the Power Stander lift, lower the client into the wheelchair, fasten the wheelchair pelvic belt, unfasten the sling, remove the calf strap, remove the lift away from the client, reposition the client in the wheelchair, and replace all wheelchair parts that were moved or swung away. However, DCS 8 had unfastened Client 5's sling before his wheelchair pelvic belt was fastened.
Review of the manufacturer's guidelines for the StandUp sling showed the StandUp sling is suitable for clients who can follow instructions, have good stability in the torso, and can load and support at least one leg. However, Client 5 was unable to stand or bear weight.
Review of the facility's P&P titled Client Transfer Policy effective 2/1/07, showed in part: the clients will be identified by the Interdisciplinary Team (IDT - a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the client) as to the safest method of transfer. No staff person will be allowed to perform a one person lift under the new policy. Information regarding client transfers will be included in the client's Strengths and Needs list and in each Individual Service Plan (ISP - the written details of the supports, activities, and resources required for the individual to achieve personal goals.) The OT and PT assessments will address client transfer skills during their annual assessments and as client needs change. An up-to-date list of required transfer procedures for each client will be posted at each location for easy access and reference by staff. Staff will receive training on the safe and proper use of the transfer equipment.
During a tour of the facility on 7/19/17 at 0915 hours, the Surveyor was unable to locate an up-to-date list of the required transfer procedures for each client as required per the facility's Client Transfer P&P.
During an interview and concurrent facility tour with the Assistant Administrator on 7/19/17 at 0920 hours, the Assistant Administrator verified the facility did not keep a list of the required transfer procedures for each client posted in the facility. During the facility tour, there were two different types of Hoyer lifts (a Power Stander lift and a full-body sling lift) observed on each of the hallways: the men's hallway and women's hallway. The Assistant Administrator stated they called both types of lifts "Hoyer lifts." When the Assistant Administrator was asked how the staff knew which type of lift to use for each client, the Assistant Administrator stated the facility staff were trained on the client's transfer ability when a new client was admitted or when the staff was hired. When the Assistant Administrator was asked how it was determined which type of Hoyer lift (Power Stander or full-body sling lift) was to be used for each client, the Assistant Administrator stated the type of Hoyer lift to be used for each client was determined by the PT upon admission.
On 7/19/17 at 0926 hours, Client 5's recapitulated Physician's Orders dated July 2017 were reviewed. Review of the Physician's Orders failed to show a physician's order indicating how Client 5 was to be transferred.
Review of Regional Center of Orange County(RCOC)'s Annual Individual Program Plan (IPP - a person centered plan to assist the client to build their capacities and capabilities) Review dated 11/2/16, showed Client 5 was wheelchair bound and was unable to bear weight on his lower extremities.
On 7/19/17 at 1040 hours, an interview and concurrent clinical record review was conducted with the QIDP. The QIDP verified the above findings. The QIDP was shown both the PT report dated 1/15/17, and RCOC's Annual IPP report dated 11/2/16, showed Client 5 did not bear weight and was a full transfer. When asked how it was determined the Power Stander lift was to be used by Client 5 instead of the full-body sling lift, the QIDP stated, "We assessed him when he was admitted and decided how to transfer him." When the QIDP was asked to provide documentation of the assessment showing Client 5 should be transferred via the Power Stander lift, he stated he was not sure if he documented the assessment. The QIDP stated if he documented the assessment it would be located in the Client's IDT notes. However, review of Client 5's IDT notes failed to show documentation of Client 5's transfer assessment.
The facility failed to ensure Client 5 was assessed by the IDT to determine the safest method of transfers and the OT and PT assessments addressed the client transfer skills. The facility failed to ensure adequate supervision and interventions were provided to Client 5. As a result, Client 5 fell two times while being transferred via a Hoyer lift and fractured his nose.
This failure had a direct and immediate relationship to the health, safety, and security of the client. |
| 010000080 |
Ukiah Post Acute |
110010928 |
A |
01-Oct-14 |
VXL911 |
17728 |
F323 ?483.25(h) Free of Accident Hazards/Supervision/Devices The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. The facility violated the regulation by failing to ensure that Resident 1, who was at high risk for falls and known attempts to get out of bed and the wheelchair unassisted, was provided adequate supervision by direct care staff and had effective revisions and development of an individualized care plan for Resident 1 to prevent further falls to keep Resident 1 safe. Resident 1 had eight falls during a six month period from 12/11/13 to 6/9/14. These failures caused Resident 1 to sustain a right hip fracture after falling while attempting to ambulate unassisted and required Resident 1 to undergo right hip surgery. Resident 1's admission record indicated that Resident 1 was admitted to the facility on 11/8/13, with diagnoses including muscle weakness, Alzheimer's disease (a brain disease causing memory loss, impaired thinking and disorientation), personal history of fall, and lack of coordination. The fall risk evaluation dated 11/9/13 and 12/2/13 revealed that Resident 1 was at high risk for falls due to multiple problems including mental status problem, history of falls, and gait/balance problems. The Admission Minimum Data Set (MDS, an assessment tool), dated 11/15/13 and the most recent quarterly MDS, dated 5/12/14, indicated Resident 1 had short-term and long-term memory problems, moderately impaired cognition, unsteady gait/balance, required extensive assistance with transfers, walking, dressing, and risk for falls. The Care Area Assessment (CAA, a tool used to identify resident concerns and develop an individualized care plan), dated 11/21/13, indicated Resident 1 had history of falls, impaired safety awareness, impulsiveness, cognition and balance problem, and Alzheimer's type dementia. A care plan for At Risk for Falls indicated: "1) Alarm devices (a device attached to the resident that triggers an alarm when the resident attempts to get up from the wheelchair or bed) as indicated and educated resident as to reasons. Remind resident to call for and wait for staff assistance before getting up OOB (Out of Bed) or chair; 2) Anticipate and meet needs; 3) Bed in lowest position; 4) Be sure the call light is within reach and encourage to use it to call for assistance as needed; 5) Floor mat." The goals included that Resident 1 would have no falls or injuries. First Fall: The nurse's note, dated 12/11/13, indicated on 12/11/13 at 9:30 a.m., Resident 1 had an unwitnessed fall. The nurse' note indicated that Resident 1 was found sitting on the floor mat at the right side of the bed.The care plan regarding at risk for falls for Resident 1 indicated that, on 12/11/13, Resident 1 required one to one staffing assignment due to increased confusion, combative behavior, and wandering. The care plan indicated that the intervention of one to one staffing assignment was added on 11/9/13 and discontinued on 12/13/13. During an interview on 7/28/14, at 12:10 p.m., Administrative Staff B stated that she could not find any documentation showing one to one staffing assignment for Resident 1 except on the care plan. She also stated that she did not know why the intervention, one to one staffing assignment, was initiated and discontinued. When asked if the resident required "one to one staffing assignment due to increased confusion, combative behavior, and wandering," (per the care plan,) Administrative Staff B stated that a staff member should be with the resident at all times. Second Fall: The nursing post fall assessment, dated 12/12/13, indicated on 12/12/13 at 9:10 p.m., Resident 1 was found on the floor next to the bathroom door. Resident 1 sustained a skin tear on her right arm from this fall. The Fall Committee IDT (interdisciplinary team) note, dated 12/30/13 (18 days after two falls on 12/11/13 and 12/12/13), indicated "New interventions" were: 1) Place resident in common areas when out of bed; and 2) RNA (Restorative Nursing Assistance) program for ambulation and lower extremity strengthening. The IDT note and the care plan lacked specificity and did not indicate providing supervision to Resident 1 to prevent further falls. The care plan reflected that the continuous intervention included, "Be sure the call light is within reach and encourage to use it to call for assistance as needed." The MDS dated 11/15/13 indicated that Resident 1 made poor decisions and required cues and supervision. The care plan lacked specificity of how Resident 1 was going to call for help when she required cueing and supervision. The care plan did not specify providing supervision to Resident 1 to prevent further falls.During an interview on 6/17/14, at 11:35 a.m., Unlicensed Staff E stated that Resident 1 was confused and was not able to use the call light and wait for assistance. Unlicensed Staff E stated that she just put the call light within reach of the resident. She also stated that she would not remind the resident to wait for assistance because the resident was confused. Unlicensed Staff E further stated that staff would go in the resident's room and check on the resident if the alarm sounded. During an interview on 6/19/14 at 3:15 p.m., Management Staff A was asked the reasons for taking 18 days to have a Fall Committee IDT meeting and develop new interventions. She stated that, "I cannot answer that...I was not here that time." When she was asked how would the intervention, "keep in common areas when out of bed" prevent Resident 1 from falling, she stated that the common areas included hallways and the day room. She stated that the staff left the resident in common areas so that staff could keep an eye on the resident when they performed other tasks or when they were near the resident. When asked what happened if no staff was near the resident, she stated that nobody watched the resident. During an interview on 7/28/14 at 2:25 p.m., Licensed Staff G stated that on 12/12/13, prior to Resident 1's fall, no staff supervised the resident. Licensed Staff G stated that Resident 1 went to the bathroom by herself and fell. She further stated that the staff went into the resident's room when the resident's alarm sounded and found the resident was on the floor near the bathroom. Licensed Staff G stated that if a resident was on one to one staffing assignment, a staff member should be with the resident at all times. Third Fall: The nursing post fall assessment, dated 1/8/14, indicated on 1/8/14 at 2:15 p.m., Resident 1 was found sitting on the floor mat. The Fall Committee IDT note, dated 1/10/14, indicated "New intervention of wedge cushion (a type of cushion used in bed) for positioning as fall intervention." The IDT note and care plan lacked specificity and did not indicate providing supervision to Resident 1 to prevent further falls. During an interview on 6/19/14, at 3:15 p.m., when Management Staff A was asked how the wedge cushion prevented the resident from falling out of the bed, she stated that the wedge cushion was for positioning but could not keep the resident from falling out of the bed.Fourth Fall: The nursing post fall assessment, dated 2/13/14, indicated on 2/13/14 at 7 p.m., Resident 1 tried to pick something up on the floor and slid out of the chair. The Fall Committee IDT note, dated 2/14/14, indicated the plan was to continue current interventions for fall prevention; request physical therapy (PT) screening; and recommend Dysem (non-slip material) for the wheelchair to prevent sliding. The care plan lacked specificity of providing supervision to Resident 1 to prevent further falls. During an interview on 6/19/14, at 3:15 p.m., when Management Staff A was asked how the Dysem prevented Resident 1 from getting up from the wheelchair unassisted, she stated that the Dysem helped prevent Resident 1 from sliding out the wheelchair. She further stated that the resident could still stand up and walk. The PT evaluation dated 3/11/14, indicated that Resident 1 "...Has difficulty following simple motor commands and has little to no safety awareness..." Fifth Fall: The nursing post fall assessment, dated 3/22/14, indicated on 3/22/14 at 6:45 a.m., Resident 1 was found sitting on the floor next to her bed in front of the wheelchair and the resident was unable to describe the fall. The Fall Committee IDT note, dated 3/24/14, indicated on 3/22/14, Resident 1 fell out of bed at 6:30 a.m. New interventions were: 1) Request physician to review medications for insomnia; and 2) Assist resident out of bed at 6:30 a.m. The IDT note and the care plan lacked specificity of providing supervision or monitoring to Resident 1 to prevent further falls. The fall risk assessments, dated 3/18/14 and 3/24/14, indicated Resident 1 was a high risk for falls due to multiple problems including mental status problem, history of falls, gait and balance problems. Sixth Fall: The Fall Committee IDT note, dated 4/9/14, indicated Resident 1 fell from her wheelchair on 4/4/14 (no time provided). The Fall Committee IDT note indicated interventions included 1) Therapy to screen for occupational therapy services; 2) Activities to review the care plan; and 3) Continue with current fall interventions/alarms. The care plan interventions included a body alarm for the wheelchair (a device attached to the resident and the wheelchair that triggers a noise when the resident attempts to get up); and a pressure pad alarm for the bed (a pad placed on the bed that alarms when the patient attempts to get up). The care plan lacked specificity of how staff provided supervision and monitoring of the resident to prevent further falls. The fall risk assessment, dated 4/8/14, indicated Resident 1 was at high risk for falls due to multiple problems including mental status problem, history of falls, gait and balance problems. Seventh Fall: The nursing post fall assessment, dated 4/13/14, indicated on 4/13/14 at 4:55 a.m., Resident 1 fell from her wheelchair in the hallway. The nursing post fall assessment indicated the immediate interventions included visual check every 10 minutes and supervision "constantly". However, the Fall Committee IDT note and the care plan did not indicate the intervention for visual check every 10 minutes and supervision "constantly." The Fall Committee IDT note, dated 4/14/14, indicated Resident 1 continued "to be at risk for falls due to impaired cognition, balance and poor safety awareness." The Fall Committee IDT note indicated that, "New intervention" was to request occupational therapy. The IDT note and care plan lacked specificity of how staff provided supervision to prevent further falls. During an interview on 6/17/14, at 3:15 p.m., Management Staff B was asked to define "constant monitoring or supervision." She stated that staff would watch the resident every one to two hours. She stated there was no set time frame or assigned staff to monitor and supervise the resident. She stated staff would watch the resident during rounding or passing by the resident. During an interview on 6/17/14 at 3:25 p.m., Licensed Staff G stated that "constant monitoring or supervision" meant to watch the resident every 20 minutes. During an interview on 6/19/14, at 3:15 p.m., Management Staff A stated that "constant" meant all the time. When queried that the care plan and other documents did not indicate "supervise constantly," Management Staff A stated that she reviewed the care plan and the IDT notes and stated "I do not see that too." When asked about care planning and implementing supervision to Resident 1, Management Staff A stated, "It is not specified." When Management Staff A was notified that staff gave different answers for the definition of "constant monitoring or supervision" (every 20 minutes, every one or two hours), she stated, "Then we need in-services." The fall risk assessment, dated 4/14/14 and 5/26/14, indicated Resident 1 continued to be a high risk for falls due to multiple problems including mental status problem, history of falls, and balance problem. During an interview on 6/17/14, at 12:02 p.m., Licensed Staff C stated that Resident 1 was at high risk for falls. He stated that Resident 1 was not able to use call light because she was confused, forgetful, and had memory problems. Licensed Staff C stated that staff put the call light for every resident. He also stated that the care plan for Resident 1 needed to be updated. During an interview on 6/17/14, at 2:25 p.m., regarding the intervention, "Continue interventions on the at-risk plan" in the care plan initiated on 12/13/13, Management Staff A stated that she assumed that the at-risk plan was the care plan and the severity of the resident's risk. She further stated that the care plan for Resident 1 was not individualized. Eighth Fall: The Fall Committee IDT note, dated 6/10/14, indicated on 6/9/14 at 1:50 p.m., Resident 1 fell to the floor when she attempted to ambulate without assistance. The nursing note dated 6/9/14 indicated that the occupational therapist (OT) witnessed the fall and the body alarm did not sound. Resident 1 was sent to an acute care hospital. During an interview on 6/13/14, at 12 p.m., the OT stated that on 6/9/14 at 1:50 p.m., Resident 1 fell in the hallway near the nurse station. The OT stated that she was working on another resident's paperwork in the hallway and did not know Resident 1 was behind her. She felt that a person was falling on her back so she turned around and noted that Resident 1 stood up near her wheelchair and was falling. She stated that she tried to hold Resident 1 to break the fall; however, Resident 1 fell and both the OT and Resident 1 were on the floor. She stated that Resident 1 was alert and complained of hip pain. The OT stated that she did not hear Resident 1's body alarm sound. The OT also stated that Resident 1 was in the hallway alone. No other staff was around. She had to yell out for help. During a concurrent observation and interview on 6/17/14, at 10:45 a.m., Resident 1 was in bed and was awake. When asked how she would call the staff for help when the staff were not in her room, Resident 1 stated, "I do not know." When asked about the call light, Resident 1 pointed at her blanket and stated, "I do not know. That is all I have." During an interview on 6/19/14, at 3:15 p.m., when Management Staff A was asked how the facility had provided adequate supervision for Resident 1, she stated that she could not answer the question for the first fall to the seventh fall. Management Staff A stated that the facility provided adequate supervision for the eighth fall because on 6/9/14, prior to the fall, the staff assisted Resident 1 for eating, toileting, and positioning. She further stated that the OT was not intended to supervise Resident 1, but the OT reacted appropriately to assist the resident when she fell. The acute care hospital emergency department notes and x-ray result, dated 6/9/14, indicated that Resident 1 sustained a right hip fracture from the fall. Resident 1 was admitted to the acute hospital on 6/9/14 and had a surgical repair of the right hip. The fall risk evaluation for Resident 1 on admission (Resident 1 was re-admitted to the facility), dated 6/13/14, indicated that Resident 1 was at high risk for falls. The care plan for at risk for falls was not initiated until 6/23/14.During an interview on 8/4/14, at 1:50 p.m., Management Staff A stated that the facility had a previous care plan for at risk for falls and the care plan was discontinued on 6/18/14. Management Staff A also stated that the facility initiated a new care plan on 6/23/14. Management Staff A further stated that the facility had 21 days to complete the care plan. When asked how would staff know what interventions should be provided to the resident between 6/18/14 and 6/23/14 (without a care plan), Management Staff A stated that the staff knew Resident 1 because the resident was a re-admission, and staff knew some of the interventions from the treatment sheet.The facility policy and procedure titled, "Fall Risk Assessment," dated 5/2012, indicated "Any resident identified as high risk will have a prevention protocol initiated and documented on the care plan. Prevention protocol examples...Provide supervision..." The facility policy and procedure titled, "Fall Management System," dated 6/2013, indicated "Residents with a Falls Risk Assessment score of 10 or above are considered high risk and will have an individualized care plan developed that includes measurable objectives and timeframes." Therefore, the facility violated the regulations by failing to ensure that Resident 1, who was at high risk for falls and known attempts to get out of bed and the wheelchair unassisted, was provided adequate supervision by direct care staff and had effective revisions and development of an individualized care plan for Resident 1 to prevent further falls to keep Resident 1 safe. Resident 1 had eight falls during a six month period from 12/11/13 to 6/9/14. These failures caused Resident 1 to sustain a right hip fracture after falling while attempting to ambulate unassisted and required Resident 1 to undergo right hip surgery. The violation of the regulation had presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 010000080 |
Ukiah Post Acute |
110012051 |
B |
22-Sep-16 |
8SSQ11 |
4036 |
1418.91(a) Health & Safety Code 1418 (a) A long-term health care facility shall report all incidents of alleged abuse or suspected abuse of a resident of the facility to the department immediately, or within 24 hours. 1418.91(b) Health & Safety Code 1418 (b) A failure to comply with the requirements of this section shall be a class "B" violation. The facility failed to report an allegation of abuse of Resident 12 to the Department of Public Health, State Licensing and Certification Agency immediately or within twenty-four hours. This failure resulted in the Department's inability to independently investigate the abuse allegation without delay, had the potential for residents to be exposed to further abuse. On 2/9/16, the facility reported to the Department that on 7/9/15, Management Staff B received a phone call from the Medical Director that Resident 12 was allegedly sexually assaulted by an outside visitor known to the resident. The date of incident was not known. During a review of the clinical record for Resident 12, the Face Sheet (admission record) indicated Resident 12, was admitted to the facility on 11/10/14 and discharged home on 2/25/15. The Minimum Data Set (MDS) (an assessment tool) Section I, dated 11/10/14, indicated multiple active diagnoses including post fracture, depression, psychotic disorder. Section C - Cognitive Patterns, Brief Interview for Mental Status (BIMS) indicated a summary score of 15/15 (15 denotes the resident was able to understand and is oriented to year, month and day). During an interview, on 2/9/16 at 4:05 p.m., Management Staff B stated she became aware of the incident on 7/9/15 from the Medical Director via telephone while out of the building and out of town. She stated she emailed Management Staff A on 7/9/15 at 8:36 a.m., and informed him of the alleged sexual assault concerning Resident 12. She stated Licensed Staff N began the investigation. She stated she did not report the incident to the Department because the police were investigating the incident, and because Resident 12 was no longer a resident in the building. The following day the police returned within 24 hours and said it did not happen. During an interview, on 2/9/16 at 5:00 p.m., Management Staff A stated he became aware of the incident from Management Staff B on 7/9/15. He stated he did not report the incident to the Department because the police were investigating the incident, and because Resident 12 was discharged from the facility in February 2015 and was no longer a current resident in the facility. The facility's follow-up investigation, dated 2/12/16, indicated Resident 12 had discharged from the facility on 2/25/15. On 7/9/15 the Medical Director reported to Management Staff B that the resident had reported the alleged incident to an outside medical provider. The follow up investigation noted that soon after the facility received notification by the local police department, the resident recanted the allegation and therefore the facility felt the reporting requirements were complete. The investigation report noted that Management Staff A recognized as a mandated reporter, timely reporting to the Department would have been prudent. The facility policy and procedure titled, "Abuse Prevention" revised 6/2015, indicated "All alleged violations will be reported via phone or in writing within 24 hours to the State Licensing Agency. The SOC-341 Report of Suspected Dependent Adult/Elder Abuse will be faxed to the Ombudsman within 24 hours. The facility shall follow-up to the State Licensing Agency in writing the findings and result of the completion of the investigation within 5 days." Therefore, the facility failed to report an allegation of abuse of Resident 12 to the Department of Public Health, State Licensing and Certification Agency immediately or within twenty-four hours. This failure resulted in the Department's inability to independently investigate the abuse allegation without delay, had the potential for residents to be exposed to further abuse. |
| 240000289 |
Upland Rehabilitation And Care Center |
240008877 |
A |
04-Jan-12 |
7TT111 |
16033 |
REGULATION VIOLATION: Title 22 72423 Speech Pathology and/or Audiology Service Unit - Services. (a) "Speech pathology and/or audiology services" means those services referred or ordered by a physician which provide diagnostic screening and preventive and corrective therapy for persons with speech, hearing and/or language disorders. AND (c) A speech pathology and/or audiology service unit shall meet the following requirements:(1) Patient health records shall contain a patient's history and signed orders for treatment. The facility failed to ensure the contracted ST (speech therapist) obtained signed orders from the physician to change Patient A's diet. On January 23, 2008, Contracted ST 1 changed Patient A's diet order from NPO (nothing by mouth), with gastrostomy tube feedings (feedings through a tube inserted into an opening in the stomach), to mechanical soft foods with honey thick liquids, two times a week for one week. In addition, on January 26, 2008, Contracted ST 1 fed Patient A a finely chopped meal with thin liquids. Additionally, on January 27, 2008, Contracted ST 1 ordered unthickened water and coffee to be left at the patient's bedside. However, the patient's physician did not co-sign in approval of (authorize) the dietary changes ordered by the speech therapist.72523 Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. The facility failed to ensure written patient care policies and procedures that addressed "Clinical Standards of Practice" were consistently implemented. The policy and procedure stipulated that all rehabilitation services, which included speech pathology services, would provide care and services only when authorized to do so by a signed physician's order. On January 23, 2008, January 26, 2008 and January 27, 2008, Contracted ST 1 provided Patient A with a diet that was not ordered by the physician. On February 2, 2008, Patient A was transported to the acute care hospital emergency room after being found in respiratory distress. Patient A was diagnosed with acute respiratory failure and aspiration pneumonia. Patient A died on February 7, 2008. According to Business & Professions Code, Chapter 5.3., Speech-Language Pathologists and Audiologists, Article 1, Section 2530.2(d)(1) and (2), speech therapy includes swallowing therapy.Patient A was a 63 year old male, admitted to the facility on December 27, 2007, with diagnoses including aspiration pneumonia [infection and inflammation of the lungs due to aspiration (the sucking in of food particles or fluids into the lungs)] and dysphagia (difficulty swallowing). Patient A was transferred to the facility from a specialty hospital. Documentation noted within a "Significant Change" MDS (Minimum Data Set) assessment, dated January 3, 2008, showed Patient A had moderately impaired decision making skills secondary to dementia. The clinical record for Patient A was reviewed at the skilled nursing facility on June 27, 2008. Review of Patient A's esophagram (x-ray examination of the esophagus) results from the transferring facility, dated December 14, 2007, included an "impression" of "aspiration during the examination and residue of the contrast material in the valleculae (groove or furrow on the cartilage structure that over hangs in the back of the throat area) and in the piriform (front part of the nasal opening) sinus." Review of the transferring facility's Dysphagia Evaluation, dated December 10, 2007, documented by a speech therapist, indicated Patient A had delays in swallow triggers for pureed consistency food, thick liquids, and thin liquids. The Dysphagia Summary from the transferring facility indicated Patient A had a suspected delay in swallow trigger and overt signs of aspiration with thin and nectar thick liquid. Review of Speech-Language Therapy Daily Progress Record, dated December 10, 2007, showed Patient A demonstrated significant coughing and choking when given puree and honey thick liquids, as well as increased signs of aspiration. The note further indicated the safest diet for the patient is NPO (nothing to eat or drink by mouth). The recommendation to keep the patient NPO was further documented on December 12, 2007, December 18, 2007, December 19, 2007, and December 26, 2007 by the speech therapist. Review of the transferring facility's Physician Progress Notes, dated December 23, 2007, included the following, "Severe aspiration, gastric tube placed." Physician Progress Notes, dated January 22, 2008, indicated Patient A was currently NPO and on gastrostomy tube feedings for risk of aspiration. The physician documented the patient wanting to eat. The physician documented, "However, there are risks."Physician Orders, dated January 22, 2008, written and signed by Patient A's physician, indicated an order for a swallow evaluation to evaluate the patient's oral intake status. Review of the dysphagia evaluation form showed the results of Patient A's swallow evaluation done on January 23, 2008, by a contracted Speech Therapist (Contracted ST 1). The "SLP EVAL-DYSPHAGIA" form, dated January 23, 2008, indicated the patient had a medical history of aspiration pneumonia and dysphagia with gastrostomy tube. Contracted ST 1 documented Patient A had a video examination conducted which showed aspiration. The impression was, "Due to video information, I think it would be safer for him to have ST (speech therapy) for oral grat (gratification) at lunch." Contracted ST 1 documented Patient A had "weak lips, weak tongue, weak buccal, weak mastication, fair to poor cough strength, and fair to poor laryngeal elevation."Review of a telephone order, written by Contracted ST 1, dated January 23, 2008, showed Patient A was to have mechanical soft foods for oral gratification with honey thick liquids, to be given two times a week for one week, then to be re-evaluated by the facility staff Speech Therapist (Facility ST 2) on January 28, 2008. This order was written by Contracted ST 1, despite his knowledge of Patient A's history of aspiration pneumonia. The patient's physician did not sign the order to show approval/authorization for the diet change. Review of the rehabilitation notes, dated January 23, 2008, written by Contracted ST 1, indicated he gave Patient A a trial of mechanical soft food and that the patient did an "adequate job" with eating a ham sandwich. Contracted ST 1 documented that upon further review of Patient A's record, Contracted ST 1 became aware that Patient A had a video swallow study which indicated silent aspiration (aspiration or sucking in of food particles or fluids into the lungs without causing symptoms). Review of the licensed nurses' notes, dated January 23, 2008, referred to the patient being NPO and the need to continue GT (gastrostomy tube) feedings. Review of Patient A's Daily Medicare Notes (nursing notes), dated January 26, 2008, indicated Contracted ST 1 saw Patient A at 12:15 PM and fed the resident a fine chopped diet and thin liquids. The note further indicated, "No new orders received D'cing (discontinuing) NPO status."Review of Physician Orders, dated January 27, 2008, indicated an order written by Contracted ST 1 that Patient A may have water and coffee at bedside without thickener. The order was not signed by the patient's physician. This order was written by Contracted ST 1, despite his (Contracted ST 1) knowledge of the patient's history of aspiration. Review of rehabilitation notes, dated January 27, 2008, written by Contracted ST 1, indicated Patient A was given an oral trial of mechanical soft texture for which the patient consumed approximately 50% and most of the liquid. The documentation indicated Patient A sometimes needed to be reminded to use "chin tuck swallow." On January 27, 2008, the licensed nurse documented a reference to Patient A's continued GT feedings and NPO status.During an interview with the facility staff Speech Therapist (Facility ST 2) on June 27, 2008 at 12:00 PM, she stated she was the facility's staff speech therapist and her duties were taken over by a contracted speech therapist (Contracted ST 1) while she was on vacation during the week of January 20, 2008, until she returned to duty on January 28, 2008. She further stated she performed a "screen" of Patient A when he was admitted to the facility and recommended he remain NPO. ST 2 stated the day she returned from vacation, January 28, 2008, she was notified by the nursing staff that Patient A had a swallow evaluation on January 23, 2008 and was given a trial feeding. Facility ST 2 stated she consulted with the physician and obtained an order for Patient A to discontinue all oral intakes and return to NPO status. Facility ST 2 stated, in her professional opinion, Patient A was at risk for aspiration and it was not safe to give the patient oral food or drink due to his history of aspiration pneumonia. Review of Patient A's Daily Medicare Notes, dated February 2, 2008 at 11:30 AM, indicated the patient was experiencing lethargy, labored breathing, congestion bilateral lungs, and signs of shortness of breath. The licensed nurse documented she notified the physician and an order was received to transfer Patient A to an acute care hospital for evaluation and treatment. Daily Medicare Notes, dated February 2, 2008 at 12:15 PM, revealed Patient A left the facility via ambulance. An ambulance transport document, dated February 2, 2008, included the following description of Patient A, "Appeared to be in severe respiratory distress" upon arrival at the skilled nursing facility. A visit was made to the acute care hospital on July 8, 2008. Patient A's acute care hospital record was reviewed. A History and Physical, dated February 2, 2008, dictated by the admitting physician from the acute care hospital, showed Patient A's "Chief Complaint" was, "Aspiration pneumonia with respiratory insufficiency, the lungs had bibasilar rales (fluid moving back and forth in the air passages at or near the base of both lungs) and decreased sounds, and the admitting diagnosis was aspiration pneumonia bibasilar [infection and inflammation at or near the base of the lungs due to aspiration (the sucking in of food particles or fluids into the lungs)] with respiratory insufficiency." A pulmonary physician's progress note, dated February 3, 2008, included the following "impression," "(a) Acute respiratory failure; and (b) Aspiration Pneumonia." A Patient Care Note, from the acute care hospital, dated February 7, 2008 at 5:37 AM, revealed Patient A's cardiac monitor showed asystole (no heart beat). Review of the Clinical Summary, dated March 7, 2008, showed Patient A was admitted to the acute care hospital on February 2, 2008 and expired on February 7, 2008. The discharge diagnoses included bilateral aspiration pneumonia with respiratory failure. In the Hospital Course section, the physician described Patient A's hospital stay, which began with the patient's respiratory failure and transfer to the intensive care unit, where he had cardiopulmonary arrest on February 6, 2008 and died on February 7, 2008, "despite resuscitation efforts." Review of Patient A's Death Certificate, dated February 14, 2008, listed the patient's cause of death as "(A) Cardiorespiratory Arrest" and "(B) Bacterial Pneumonia." During an interview with the skilled nursing facility's Director of Nursing (DON) on July 10, 2008 at 9:00 AM, she stated she interviewed Contracted ST 1 during her investigation of the incident. The DON stated Contracted ST 1 was unaware of facility policies and procedures and did not know he needed to consult with the physician for treatment orders. She stated Contracted ST 1 did not consult with the physician regarding treatment orders and plans for Patient A. During a follow-up interview with the DON on July 10, 2008 at 11:10 AM, she stated she had spoken with Patient A's physician during the investigation process and stated the physician said he did not sign Contracted ST 1's written telephone orders because he did not authorize the treatment Contracted ST 1 gave to Patient A. During an interview with Licensed Vocational Nurse (LVN) 1 on July 16, 2008 at 9:00 AM, she stated she was frequently Patient A's primary nurse. She stated Patient A came back to the facility with a gastrostomy tube, had difficulty swallowing, and was NPO. LVN 1 stated Contracted ST 1 came in on January 23, 2008 to perform a swallow evaluation for Patient A, and during that visit Contracted ST 1 fed and gave Patient A "things to drink." LVN 1 stated she noted the order written by Contracted ST 1 on January 27, 2008 indicating Patient A could have unthickened water and coffee at bedside. She stated at that time she spoke to the rehabilitation director and told him she was concerned because Patient A would cough, turn red, and lose his breath when he attempted to consume liquids. LVN 1 also stated she did not give Patient A anything to eat or drink because the physician told her to keep the patient NPO and did not discontinue the NPO order. LVN 1 further stated Patient A became lethargic and had labored breathing on February 2, 2008. She called the physician and received a verbal order to send the patient to the acute care hospital. The facility rehabilitation policy and procedure titled "Physician's Order," dated January 2003, included the facility's policy that stipulated all orders and/or changes in orders must appear on the physician's order sheet and be verified with a telephone order from the physician. Procedure #1 showed the order was to be obtained by a physician and would be clarified with the primary attending physician. The facility's rehabilitation policy and procedure titled "Clinical Standards of Practice," dated January 2003, revealed all rehabilitation services provided were to be authorized by a signed physician's order. The facility rehabilitation policy and procedure titled "Staff Speech-Language Pathologist," dated January 2003, referred to the "job summary," which included development of effective treatment plans and obtaining approval for services from referring physician. The policy included the need to treat the patients according to the physician's treatment plan. During a telephone interview with Patient A's primary physician on August 5, 2008 at 3:54 PM, he stated Contracted ST 1 did not, at any time, consult with him regarding the swallow evaluation assessment of the patient. He further stated he did not give Contracted ST 1 orders to give a mechanical soft diet to Patient A, nor did he give orders to provide Patient A with unthickened water and coffee at bedside. Patient A's physician further stated a swallow evaluation consisted of giving the patient progressive liquid trials beginning with water, then honey consistency, then puree consistency, and did not include a trial of solid food. According to the information obtained, the facility failed to ensure Patient A's health records contained signed orders for treatment. ST 1 wrote treatment and diet orders without consulting with the patient's physician and without obtaining authorization by the patient's physician. ST 1 provided unauthorized treatment to Patient A, which resulted in Patient A developing severe respiratory distress, subsequent hospitalization and death.The facility further failed to implement patient care policies that stipulated physician orders for speech pathology treatments, which included dietary changes, must be obtained prior to providing the services. Contracted ST 1 was not aware of facility policies and procedures that pertained to physician orders for new treatments or treatment changes. This failure resulted in Patient A's death due secondary to aspiration pneumonia. The violation of the above regulation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 240000289 |
Upland Rehabilitation And Care Center |
240008902 |
B |
12-Jan-12 |
401N11 |
7739 |
REGULATION VIOLATION: Title 22 72311 Nursing Services - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (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. And(a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition.The facility failed to develop a patient care plan to address prevention of falls, which would include measurable and time-limited objectives, as well as the staff responsible for implementing the approaches for the care plan. The facility failed to ensure Patient A's plan of care pertaining to fall prevention included evaluating and updating the plan at least quarterly. On July 30, 2011 at 11:50 AM, Patient A was observed by a facility visitor lying on the street in front of the facility. Patient A was subsequently transferred to the general acute care hospital and diagnosed with a fractured right hip. On August 4, 2011 at 1:50 PM, an unannounced visit was made to the facility to investigate the incident involving Patient A. This facility is a 206-bed facility which is situated with the front of the facility facing a street which has been observed to be a heavy traffic street.Patient A was admitted to the facility originally on March 29, 2005 with the most recent readmission date of November 26, 2009. Patient A's diagnoses included muscle weakness, depression, dementia (a loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior), psychosis (a loss of contact with reality, usually including false beliefs about what is taking place or who one is (delusions) and seeing or hearing things that aren't there (hallucinations) and dialysis (a process used to remove waste and excess water from the blood).The medical record included a fall risk assessment form (a form used by long-term care facilities to evaluate the risk for potential falls). The assessment form included scores for eight clinical conditions and parameters (mental status, history of falls, and ability to walk, vision, balance, blood pressure, certain medication usage and predisposing diseases) with a total score of 10 or above representing high risk for a fall. Resident A's fall risk assessment scores were as follows: 12/15/10 = 13 02/02/11 = 13 05/01/11 = 11 07/04/11 = 9 A plan of care that addressed Patient A's "Impaired Cognitive" status (memory loss, forgetfulness) was implemented on November 26, 2009. The reason for the care plan was as follows, "Due to mild dementia." A date stamp showed the care plan was reviewed on February 18, 2011. The "Care Area Assessment Cognitive Loss Worksheet" (CAA) portion of the Minimum Data Set (MDS, a form used by long-term care facility's to assess and plan care for patients) dated February 14, 2011, indicated Patient A had, "Confusion, disorientation, and forgetfulness". A psychiatrist's progress note dated July 9, 2011, indicated the following, "Decreased cognitive ability/meaning compared to 1 - 2 years ago...monitor closely". A review of the nurse's notes dated July 30, 2011 at 11:50 AM indicated the nurse caring for Patient A was notified that the patient was found outside of the building in the highway corner of the driveway lying on his right side. The nurse further documented that the patient was in the wheelchair when she arrived. The patient was taken to his room and transferred to bed.The licensed nurses' notes showed the patient was assessed. The patient was noted to have an abrasion to the right knee and was unable to move his right leg. Documentation indicated Patient A complained of severe pain to his right hip. The physician was called, orders were received and the patient was transferred to the general acute care hospital on July 30, 2011 at 12:30 PM. The x-ray report obtained at the acute care hospital dated July 30, 2011 at 2:38 PM indicated a "right femur (thigh bone) fracture" was discovered during the x-ray examination. An interview was conducted with LVN 1 on August 4, 2011 at 3:35 PM. LVN 1 stated Patient A had been observed lying on the road in front of the facility by a visitor to the facility, who reported it to the staff. LVN 1 stated she went outside to assist and Patient A was already in the wheelchair.On August 4, 2011 at 3:55 PM, an interview was conducted with CNA 1. CNA 1 stated that on the morning of July 30, 2011 she heard over the facility radio that a patient had fallen outside. CNA 1 stated she went outside to help and when she got there she observed Patient A lying in the road on his right side. CNA 1 stated Resident A's wheelchair was on the sidewalk upright facing the patient. CNA 1 stated it appeared that Patient A may have attempted to roll himself down over the sidewalk edge, and the wheelchair stopped and the patient fell out of the front of the wheelchair into the street. CNA 1 stated Patient A did not say anything. CNA 1 stated Patient A was lifted into the wheelchair and taken back inside the facility to his room. CNA 1 further stated Patient A would often wheel himself all over the facility. CNA 1 was not sure how often Patient A went outside of the facility. CNA 1 was requested to show the location of the patient after the fall. CNA 1 pointed out an area which was approximately 8 to 10 feet east of the driveway on the west side of the building. There was a sidewalk in front of the facility then a grassy area approximately 4 feet wide between the sidewalk and the street. CNA 1 stated the wheelchair was upright in the grassy area facing the street and the patient was found on the street in the parking lane on his right side. Continued review of the medical record showed Patient A was a dialysis patient and went to a dialysis center three times a week. The record reflected Patient A had a fall at the dialysis center on February 3, 2011. On February 3, 2011, there was a "Short Term Problems" care plan initiated for the fall at the dialysis center. The approaches for the care plan were: ---monitor vital signs ---frequent visual checks ---attend to all needs ---call light encouraged ---monitor for pain The short term care plan was documented as resolved on February 5, 2011. A review of the facility's policy, "Care Planning", documented, "A comprehensive care plan is developed within (7) days of completion of the Resident Minimum Data Set (MDS)." Resident A's MDS was completed on February 14, 2011. An interview with the Director of Nurses (DON) and Assistant Director of Nurses (ADON) was conducted on August 4, 2011 at 4:45 PM. The DON and ADON were asked about the care plan for Patient A's fall risk. Both the DON and ADON confirmed there had not been any new approaches to the plan of care since November 26, 2009, when the care plan was written. The DON stated a short-term care plan had been initiated following Patient A's fall at the dialysis center on February 3, 2011 and that the fall risk care plan had been date stamped as being reviewed on February 4, 2011, but no new or different approaches had been added to the long-term care plan. The violation of the above regulations had a direct relationship to the health, safety, or security of patients. |
| 240000289 |
Upland Rehabilitation And Care Center |
240008919 |
B |
18-Jan-12 |
0KX811 |
22017 |
REGULATION VIOLATION: Title 22 72523 Patient Care Policies and Procedures and 72311 Nursing Service - General 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. And 72311 (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care which shall include (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (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 ensure that their policy pertaining to patients signing out on passes was consistently implemented for Patient A.The facility failed to ensure Patient A's plan of care was re-assessed, revised and updated with specific goals, timelines and interventions to meet the patient needs. The plan would include a mechanism for Patient A to contact the facility in case of an emergency when the patient was out of the facility. On May 31, 2010 Patient A was last seen by staff. On June 1, 2010 at around 8:00 AM Patient A was found dead, 0.06 miles from the facility. The cause of death was hypothermia. On July 16, 2010, Patient A's medical record was reviewed. Patient A, 49 years of age was admitted to the facility on March 1, 2006 and readmitted on December 23, 2008. Diagnoses included quadriplegia, (paralysis of all four limbs, both arms and both legs), seizure disorder, (a seizure is a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness (disorders that range from mild confusion to deep coma) and/or other uncontrollable body movements), hypertension, (elevated blood pressure) depression, (is a mental condition affecting an individual's mood. It is characterized by a range of negative feelings such as sadness), and agitation (characterized by purposeless, restless activity. Pacing, talking, crying, and laughing sometimes are characteristic and may serve to release nervous tension associated with anxiety, fear, or other mental stress). The Minimum Data Set, (MDS, a comprehensive assessment of the resident), completed on April 4, 2010, indicated that the patient had no problems with long or short term memory and that the patient was independent in cognitive skills for daily decision making. The patient exhibited persistent anger with self and others, and self-deprecation (tending to undervalue oneself and one's abilities) and was dependent on the staff for all care needs.On July 16, 2010 the facility's investigative summary report dated June 7, 2010 was reviewed. It indicated that on May 31, 2010 at approximately 10:30 PM, facility's staff confirmed that Patient A had not returned to the facility following his departure from the building earlier in the evening in his electric wheelchair. The search started shortly after 10:30 PM on May 31, 2010 and concluded just before 8:00 AM on June 1, 2010 when the facility was notified that Patient A's body was located 0.06 miles from the facility. Emergency services confirmed that Patient A was dead. The facility's investigative report further indicated that Patient A was alert, oriented and competent to make his own decisions. Patient A frequently left the facility to participate in outside activities of his choosing; the patient often traveled to neighborhoods surrounding the facility and to establishments, (convenience stores) in and around those neighborhoods. It was not unusual for Patient A to leave the facility in the morning or early afternoon and returned after dark, typically around 8:00 PM or after. A review of the nurse's notes dated May 31, 2010 at 11:15 PM indicated that Patient A was last seen around 5:20 PM by a Certified Nursing Assistant (CNA) leaving the facility and had not returned by 11:15 PM. The surrounding area was searched. The assistant administrator (AA) and the Upland police were called and a missing report was filed. A review of the nurse's notes dated June 1, 2010 at 3:00 PM, late entry, indicated that at 5:30 PM on May 31, 2010, the patient was administered his 5:00 PM medications. The patient was in the hall way in his electric wheel chair and no behavioral problem was observed. At 6:00 PM during rounds, Licensed Vocational Nurse (LVN) 1 and CNA 1was unable to locate Patient A.The facility policy titled, "Missing resident" revised July 2007 included the following: "In order to establish whether or not a resident is, in fact, missing, the following procedure will be implemented when the location of a resident is unknown". "This include, the sign-in/out book will be checked to determine if the resident has indicated plans to be out of the facility". On July 16, 2010 at 10:15 AM, an interview was conducted with the Administrator. The Administrator was asked how the facility tracked patients on pass or on leave from the facility. The Administrator stated that patients sign in and out on the log. The Administrator stated that Patient A could not sign the log due to his disability; Patient A did not ask staff to sign him out and that Patient A left the facility without notifying staff where he was going. The Administrator stated that when Patient A was told that he had to notify staff when he was leaving the facility, the patient responded, "I do not have to tell you where I am going. I am a grown man and I get around fine. I know what I am doing; you don't have to tell me what to do." The Administrator was asked if Patient A had a medical emergency while he was out of the facility how would he get help. The Administrator could not explain what mechanism was in place for Patient A to contact help while outside of the facility. The Administrator was asked that since Patient A was in and out of facility without staff knowledge or tracking system, how staff would know when the patient was missing. The Administrator stated that Patient A was alert, oriented, and made his own decisions; the patient had been in the facility for years and the staff were aware that that the patient came and went as he pleased.The Administrator was asked if the entrance to the facility was locked at a certain time. The Administrator stated that the facility's entrance was usually locked by 8:00 PM. The Administrator was asked how Patient A got into the facility after 8:00 PM. The Administrator stated that staff would have to let Patient A into the facility after 8:00 PM. The Administrator stated Patient A left the facility regularly, almost daily. The Administrator further stated that Patient A was observed sitting outside the facility on many occasions. In addition, the patient would travel in his electric wheel chair frequently across the parking lot to the acute care hospital where he had friends in administration.The Administrator was asked if the facility had a signing out policy for patients on pass, appointments or on leave. The Administrator stated that the facility did not have a signing out policy.On July 16, 2010, the facility's logs titled, "Release of responsibility for leave of absence" was reviewed with the Assistant Administrator (AA). The "Release of responsibility for leave of absence log" had 9 columns with the following headings: Sign date, Out Time, Facility Representative, Name of Patient, return Time, Sign of Person responsible, Sign Date, In Time, and Facility Representative. The logs indicated the following: From January 1, 2010 to July 16, 2010, only one patient had signed the log in February 2010. Patient A's name was not on the log for that time period. For 2009, Patient A was signed out on April 20, 2009 at 9:30 AM. There was no estimate of return time, sign date, actual in time or facility representative for return. No other patient was listed on the sign in/out log for 2009. There were nine blank spaces left on the log. For 2008, Patient A was signed out 6 times and had no sign in times.For 2007, Patient A was signed out 2 times and had no sign in times. On July 16, 2010 at approximately 10:15 AM, an interview was conducted with the AA. The AA confirmed that Patient A had only a few signed out times when he left or returned to the facility. The AA acknowledged that the facility's logs titled "Release of responsibility for leave of absence" were not consistently implemented for Patient A. On August 16, 2010 at 4:40 PM, an interview was conducted via the telephone with CNA 1. CNA 1 was assigned to provide care for Patient A on the evening shift (3:00 PM to 11:30 PM) on May 31, 2010 when the patient went missing. CNA 1 stated, "Patient A went in and out of the facility in his power chair. He would just go and sit in the parking lot by the bus station across from the hospital. He would sit in front of the facility, catching sun under a tree". CNA 1 stated that on the evening of May 31, 2010, at around 3:00 PM, Patient A was observed in his room visiting with 3-4 family members. Between 3:30 PM and 4:00 PM, Patient A was in his power chair accompanied by family members going towards nursing station 2's exit. Between 4:30 PM and 5:00 PM, Patient A was observed in his power wheel chair going towards nursing station 2. CNA 1 stated, "At dinner time between 5:30 PM and 6:00 PM, I noticed he was not here".CNA 1 stated that she usually fed Patient A before she went to dinner at around 8:00 PM. CNA 1 stated that she had not spoken to Patient A that evening because the patient was with family when CNA 1 shift began, and then CNA 1 was unable to locate the patient at dinner time. CNA 1 stated that when she returned from dinner at 8:30 PM, she still was unable to locate the Patient A. CNA 1 stated that when she took care of Patient A, the patient usually returned to the facility between 8:00 PM and 9:00 PM, except for Thursday nights. On Thursday nights the patient went to the Upland Street Market and would return around 9:30 PM. CNA 1 stated that between 9:00 PM and 10:00 PM that night she got worried but the staff told her not to worry because Patient A is used to staying out late, at times he would return to the facility between 12:00 AM and 1:00 AM.CNA 1 stated that at 10:30 PM she was unable locate Patient A to get him ready for bed. Patient A's roommate stated that he had not seen Patient A since earlier that evening. CNA 1 stated that she alerted the staff and they began looking for Patient A. CNA 1, stated that when she left the facility on May 31, 2010 at 11:15 PM, Patient A was not located. A review of the police officer's investigative report dated June 2, 2010 indicated that Patient A's wheel chair was found parked on the gravel (small stones) and was facing the South. Tire marks in the gravel that came from the North, led to the wheel chair. The chair had two drive wheels which were dug into the gravel, and there were mounds of gravel at the front of the wheels. The gravel orientation appeared to have resulted in the wheels rotating in a reverse direction with no chair movement in the reverse direction. The amount of gravel at the front of the left wheel was much larger than the right. The investigative report indicated that the temperature for the city of Upland on May 31, 2009 at 6:00 PM was 70.1 degrees Fahrenheit, (F). The temperature dropped to a low of 51.5 degrees F at 5:30 AM on June 1, 2010. The temperature was 59.1 degrees F at 7:43 AM on June 1, 2010 when the patient's body was located. The report further indicated that staff members reported that the patient was known to go to the area where he was found. A review of the coroner's report dated August 16, 2010 indicated that Patient A cause of death was "hypothermia due to hours of environmental exposure". (Hypothermia is a condition in which the body's core temperature drops below 95.0 degree Fahrenheit (F) which is required for normal metabolism and body functions. Body temperature is usually maintained near a constant level of 98-100 oF. If exposed to cold and the internal mechanisms are unable to replenish the heat that is being lost, a drop in core temperature occurs. As the body temperature decreases, symptoms such as shivering, and mental confusion occurs). On September 1, 2010, the facility's policy titled, "Leave, signing out on", revised July 2007, was received and reviewed. Documentation included the following: "It is the policy of this facility that all residents leaving the premises will be signed out on the Release of responsibility for leave of absence log". The procedures included the following: Each resident leaving the premises must be signed out. The sign out register must indicate the resident's expected time of return. (See Out on leave, release form). Staff observing a resident leaving the premises and having doubts about the resident being properly signed out, should notify their supervisor at once. Residents must be signed in upon return to the facility. However, the facility failed to implement their "Leave, signing out on" policy. The facility failed to consistently document on the log titled "Release of responsibility for leave of absence log," when Patient A left the facility or when he returned. Patient A did not have the capacity to sign in or out and depended on staff to sign him in and out. The staff was aware that Patient A left the facility without notifying staff, and returned to the facility at different times, day or night. On September 1, 2010, at 2:40 PM an interview was conducted via the telephone with the Administrator. The Administrator stated that the "Sign out register," the "Out on leave release form," the "Sign in/out log" and the "Release of responsibility for leave of absence" logs were one and the same and they all referred to the sign in/out log. On September 2, 2010 at 2:05 PM, an interview was conducted with the Director of Nursing (DON) via the telephone. The DON stated that she was new to the position and was not familiar with Patient A. The DON was asked how the facility determined which patients could leave the facility on pass. The DON stated that the physician documented on the annual "History and Physical Examination" form. If Box A was marked, "the resident has the capacity to understand and make decisions," then, the resident was able to make decisions for his medical care needs and where he went. The DON stated that the physician writes an order that the patient may go out on pass independently or may go out on pass or leave with responsible party.The DON further stated that for non-compliant patients, the family, social services and the interdisciplinary team (IDT) would be notified. The IDT would meet and discuss safety concerns and recommend interventions. The facility's assessment policy for patients on pass or leave was requested along with the IDT meeting minutes for Patient A. No documentation was provided indicating that the physician was aware of Patient A non-compliant with the facility policy. A review of Patient A's annual history and physical examination dated December 18, 2009, indicated that the patient had the capacity to understand and make decisions. A review of the physician's orders signed May 26, 2010, did not indicate that Patient A may leave the facility on pass independently or with responsible party. A review of the physician's orders dated December 23, 2008, pertaining to Patient A's readmission to the facility, indicated no documentation that Patient A may leave the facility on pass independently or with responsible party. The facility was unable to provide documented evidence of a physician order for Patient A to leave the facility independently or with a responsible party. On September 2, 2010, at 2:12 PM, an interview was conducted via the telephone with Social Service Designee (SSD) 1. SSD 1 stated that Patient A was non-complaint; and that the IDT and SSD 1 met with the patient and discussed the patient not notifying staff when he was leaving the facility. SSD 1 notes and the IDT meeting notes were requested.A review of SSD 1 annual review dated January 21, 2009 indicated that Patient A was up in a motorized wheel chair, traveled around the facility and across the street to the acute care hospital. There was no documentation of the patient's non-compliant behavior when he left the facility. A review of SSD 1 quarterly review dated April 21, 2009 indicated that Patient A was up in the motorized chair daily and went all over, in and out the facility, to the park and to the local stores. There was no documentation of the patient's non-compliant behavior when he left the facility. A review of SSD 1 notes dated July 16, 2009 indicated that Patient A was up daily in his motorized chair and that he wheeled himself within the facility and all over the community without signing out on pass. There was no documentation that this issue of Patient A not signing out was discussed with the patient and/or what interventions would be implemented. A review of SSD 1 quarterly review dated October 14, 2009 indicated that Patient A was up daily in his motorized wheel chair and went to the acute care hospital, park, and shopping most days without signing out on pass. There was no documentation that this issue of Patient A not signing out was discussed with the patient and/or what interventions would be implemented. A review of SSD 1 annual review dated January 11, 2010 documented that Patient A was up daily in his motorized wheel chair and wheeled all over the facility. There was no documentation of the patient's non-compliant behavior when leaving the facility. A review of SSD 1 quarterly review dated April 8, 2010 documented that Patient A was up in his motorized chair as tolerated and went to the acute care hospital and liked to be in the sun. There was no documentation of the patient non-compliant behavior when he left the facility. A review of the resident care conference with IDT members dated January 27, 2010, attended by Patient A documented, "The patient wheels around in his motorized wheel chair, leaves the facility without signing out or telling staff". There was no documentation if a discussion took place with the patient regarding possible solutions to this issue. A review of the care plan titled "Non-compliance" potential for injury, related to noncompliance as evidenced by refusal of: patient is quadriplegic informed at all times to inform nurses staff when going out of the building but refused to do so. Has motorized electric wheel chair and is able to propel self-outside of the building" dated December 23, 2008 included the following: Goal, participate in making decisions for health and personal care daily". There was no specific goal addressing the patient not notifying the staff when the patient was leaving the facility. The approach plan included the following interventions dated December 23, 2008: Explained the risk versus the benefits of being outside the building un-supervised. Provided reflectors for wheel chair as patient goes out of the building at night hours. Seat belt while in motorized wheel chair for safety. Do not force resident to comply against his wishes. Avoid threats or arguing when giving care or dealing with non-compliant behavior. Report non-complaint behavior to the PMD (primary care physician) and responsible party. Reaffirm the resident's rights to make their own choices Inform of risk and consequences of choices There was no additional revision or intervention to this care plan since the initiation on December 23, 2008. There was no documented intervention on how Patient A would seek help in cases of emergency while he was out of the facility. There was no documentation that the facility's policy, "Leave, signing out on," was explained to the patient. There was no documentation that Patient A's non-compliant behavior was reported to his physician. A review of the care plan titled, "Wheels self to acute care hospital and nearby areas during the day and night," dated April 21, 2009, documented no goal, but had a goal date of October, 2009. The interventions included: Discuss risk of crossing the street or staying out at night. Place reflector stickers to wheel chair. Request made to notify staff of planning to leave and go outside of the facility. Encouraged utilization of the sign out sheet to monitor whereabouts and ensure safety. On October 7, 2010, an interview was conducted with the DON via the telephone. The DON stated that the "Care planning" policy did not address assessment, revision or updating the care plan. The DON stated that each member of the IDT was responsible for updating the care plan that pertained to their discipline. Patient A's plan of care was not revised with interventions to meet the patient's needs. The care plan had no documentation that discussion took place between the facility and the patient regarding a compromise solution for the patient to notify the facility of his whereabouts. There was no documentation that a mechanism was in place for Patient A to contact help or the facility while he was out of the facility.Therefore, the facility failed to implement their "Leave, signing out on", policy to track Patient A's whereabouts once he left the facility. The facility failed to revise and update the plan of care plan with interventions on how the staff was to track Patient A's when he left and returned to the facility. And, the facility failed to ensure that a mechanism was in place for Patient A to contact help when he was out of the facility. These facility failures resulted in the facility inability to locate Patient A on the night of May 31, 2010 which contributed to the patient's death from hypothermia. The violation of the above regulations had a direct relationship to the health, safety, or security of patients. |
| 240000289 |
Upland Rehabilitation And Care Center |
240009054 |
B |
09-Mar-12 |
Z31911 |
5276 |
REGULATION VIOLATION: Title 22 72311 Nursing Services General and 72523 Patient Care Policies and Procedures 72311 (a) Nursing service shall include, but not limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. AND 72523 (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved.The facility failed to implement Patient A's care plan according to the methods indicated when transferring Patient A with a Hoyer Lift (a portable lifting machine). The care plan specified two staff caregivers transfer the patient using the Hoyer Lift.The facility failed to ensure their written policy and procedure pertaining to the use of the Hoyer Lift was implemented as written. As a result, on June 1, 2007 Patient A was dropped from a Hoyer Lift and sustained injuries that included a hematoma to the right side of her head.On March 18, 2008, review of Patient A's medical record showed that Patient A was an 81 year old female, originally admitted to the facility on July 6, 2005 and readmitted on August 6, 2005. The patient's admitting diagnoses included gout, hypothyroidism, depression, hypertension, anemia, and acute respiratory failure (ARF). Review of the completed Minimum Data Set (MDS) with an assessment date of July 20, 2005 showed Patient A had short and long term memory problems and had moderately impaired decision making ability. The same MDS indicated Patient A depended on facility staff for all activities of daily living (bed positioning, transferring, dressing and hygiene needs). Patient A required two or more persons to assist with transfers. Patient A was noted as requiring "total" to "extensive" staff assistance. The Nurse's Weekly Progress Notes dated February 4, 2007 to June 3, 2007, under the care plan for "self performance and support," reiterated the need for two or more staff caregivers to transfer Patient A. Review of the facility's policy and procedure pertaining to the use of portable lifting machines (Hoyer Lift), stipulated two staff were required during the use of a lifting machine. On June 1, 2007 at approximately 2:00 PM, a CAN 1 (Certified Nursing Assistant) used a Hoyer Lift to transfer Patient A from wheelchair to bed. The patient fell from the Hoyer Lift to the floor during the transfer to the bed. Patient A hit the right side of her head and right shoulder, as documented on the Nurses Notes dated June 1, 2007.A disciplinary notice dated June 4, 2007, included a description of the incident. CNA 1 documented she was aware that two staff caregivers were required when using the Hoyer Lift. However, CNA 1 stated Patient A was in a hurry to be transferred. In addition, CNA 1 documented she lifted the patient up in the Hoyer Lift, turned the patient to put her in bed and the hook came out from the lift. CNA 1 further documented she could not reach the patient before she fell to the floor. According to the disciplinary documentation, CNA 1 did not check the Hoyer Lift's attachment prior to using the lift and did not obtain another caregiver to help her. On April 17, 2008 during an interview, the CNA stated, "I positioned the patient on the Hoyer Lift, backed up and turned around to approach the bed, and suddenly the sling came off and the patient fell to the ground." Review of Nurses Notes dated June 1, 2007 at 2:00 PM, revealed the charge nurse was called to Patient A's room and found Patient A on the floor with a, "golf ball size of hematoma noted to right back upper head." Nurses Notes also indicated Patient A complained of a headache, mid chest pain, and right shoulder pain. Patient A was transported to an acute care hospital for further evaluation. The ambulance transport documentation dated June 1, 2007 showed a "chief complaint" of headache with chest pain and back pain. "Mechanism of Injury" described the patient's fall from a lifting hoist (Hoyer Lift), three feet above the tiled floor surface. Review of the acute care hospital emergency records dated June 1, 2007, showed the radiology interpretation as follows: "soft tissue hematoma adjacent to the right parietal bone (right side of head)...no associated skull fracture...no intracranial mass or hemorrhage."The radiology report showed some compression fractures (broken bones) of Patient A's spine. However, according to the documentation, it was not possible to determine whether or not the fractures were old or new.Acute care hospital emergency room documentation showed that Patient A was discharged back to the skilled nursing facility later that same evening. Documentation indicated the reason for the patient's transfer back to the facility was that no further interventions were needed.The facility failed to ensure the care plan pertaining to lifting and transfer was implemented on June 1, 2007. In addition, the facility failed to ensure the policy and procedure pertaining to the use of the Hoyer Lift was implemented, particularly the use of two staff caregivers. These facility failures had a direct or immediate relationship to the health, safety, or security of long-term health care facility patients or residents. |
| 240000289 |
Upland Rehabilitation And Care Center |
240011656 |
B |
21-Aug-15 |
3R6011 |
9549 |
Regulation Violation: 72311 (a) (3) (B) (a) Nursing services shall include, but not be limited to, the following: (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs and symptoms, or behavior exhibited by a patient. The facility failed to notify the physician when the X-ray confirmed Patient 1 was found to have a lateral dislocation of the hip bone (occurs when the ball of the thighbone moves out of place within the socket of the pelvic bone) on June 30, 2014. Patient 1 continued to have complaints of pain, and repeated weight was placed on the dislocated hip for 26 days. On July 22, 2014, Patient 1 was discharged to another facility, and was still complaining of pain to the left hip and transferred to the acute hospital the same day on July 22, 2014. Patient 1 was diagnosed with dislocated left hip prosthesis and required surgical intervention.A review of the clinical record for Patient 1, indicated Patient 1 was admitted to the facility on June 28, 2014, with diagnoses which included; aftercare following joint replacement (status post left hip surgery), history of falls and muscle weakness.A review of Patient 1's admitting physician's order dated June 28, 2014 showed Patient 1 was non-weight bearing on the left lower extremity (LLE). During an interview with Certified Nursing Assistant (CNA) 1 on October 2, 2014, she stated, whenever she provided care to Patient 1, she was complaining of constant pain to her hip. An interview was conducted with Licensed Vocational Nurse (LVN) 1 on October 2, 2014 11:25 AM, she stated Patient 1 was on three different pain medications and was still constantly complained of hip pain. Review of Patient 1's admitting physician's orders dated June 28, 2014 indicated Patient 1 was to receive medications for pain management; Fentanyl Patch (a strong prescription pain medication for moderate to severe pain) 25 mcg (micrograms)/hour-apply 1 patch transdermally (on the skin) one time a day every 3 days for pain management and Lidoderm Patch (a strong prescription pain medication for moderate to severe pain) 5% lidocaine (used to treat pain) apply 1 patch transdermally one time a day for pain management. Apply to left hip daily for 12 hours to be on at 9:00 AM and off at 9:00 PM and Percocet (narcotic pain medication, is used to relieve moderate to severe pain) 10-325 mg (milligrams) 1 tablet by mouth every 4 hours as needed for pain management for 30 days, not to exceed 3 GMS (grams) of Acetaminophen in 24 hours. Review of the clinical record showed the "Pain Assessment Flow sheet" documented by the nursing staff during their pain assessment times, for the dates from July 6, 2014 through July 21, 2014, which indicated Patient 1's pain level on a scale of 1-10 (1 having no pain and 10 being the worst pain) was consistently at 6/10.Review of the clinical record for Patient 1, showed an X-ray result for Patient 1's left hip was done at the hospital following surgery dated June 23, 2014. Another left hip X-ray done on June 24, 2014 which showed no dislocation of the left hip.During an interview with Patient 1's physician (MD 1) on October 2, 2014 at 10:30 AM, he stated he went to assess Patient 1 on June 29, 2014. According to the physician, he gave an order on June 29, 2014 to repeat the left hip x-ray on June 30, 2014. A review of Patient 1's physician's order dated June 29, 2014 showed an order for a left hip X-ray for June 30, 2014.A review of the left hip X-ray result dated June 30, 2014 indicated, "There is left hip arthroplasty (surgical procedure to replace a worn out or damaged hip with a prosthesis (an artificial joint) with lateral (sideways) dislocation... Conclusion: Dislocation of left hip arthroplasty."During an interview with the Assistant Director of Nursing on November 20, 2014 at 12:15 PM, she verified through the Registered Nurse (RN) documentation dated June 30, 2014, the physician was not notified of the result of the left hip dislocation when the result was received by the facility on June 30, 2014. She stated the physician should have been immediately notified of Patient 1's hip dislocation and communication to the physician should be reflected in Patient 1's clinical record. She stated, RN 1 no longer works for the facility. The facility policy and procedure titled, "Change of Condition Reporting" dated 05/2007, indicated, under "Routine Medical Change", 1; "All symptoms and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental...abnormal laboratory and x-ray results..." Further review of Patient 1's clinical record, showed there was no documentation to show the physician was notified of the left hip x-ray result when the dislocation of the patient's left hip was identified on June 30, 2014. During an interview with Patient 1's physician on November 17, 2014 at 3:10 PM, he was asked if he was notified of the left hip X-ray result on June 30, 2014. He stated, "I did not receive a phone call from the facility with the X-ray result." The physician stated he was not made aware of the hip dislocation.A review of the clinical record showed a telephone physician's order dated July 1, 2014 obtained by the Registered Physical Therapist (RPT) to increase Patient 1's weight bearing status from non-weight bearing on the left lower extremity to partial weight bearing (to place half of your weight on the operated extremity), despite the fact that Patient 1 had a dislocation of the left hip. During an interview with the RPT on October 2, 2014 at 11:15 AM, she was asked if she remembered treating Patient 1. She stated yes, Patient 1 received physical therapy during her stay at the facility. She further stated Patient 1 was in a lot of pain during the course of her therapy.Review of the physical therapy notes showed Patient 1 had physical therapy that began on June 29, 2014 and ended on July 21, 2014 for a total of 16 physical therapy sessions. The physical therapy treatments included: bed mobility, transfer training and safe ambulation training. During an interview with Patient 1's physician on November 17, 2014 at 3:10 PM, he was asked if he had ordered partial weight bearing on the left lower extremity for Patient 1 on July 1, 2014. The physician stated, "In what universe would I order partial weight bearing if I had received the X-ray result that confirmed a dislocation. No I did not order partial weight bearing on the left lower extremity." During an interview with RPT on November 20, 2014 at 11:50 AM, she stated on July 1, 2014 she phoned the ortho doctor and received an order to advance Patient1's weight bearing status from non-weight bearing to partial weight bearing. She admitted she was not made aware of the left hip dislocation until Patient 1 was discharged from the facility. RPT stated Patient 1 received physical therapy since June 30, 2014 through July 21, 2014 with dislocated left hip. She stated the nurse should have informed her (physical therapy) of the left hip dislocation when it was identified on the x-ray on June 30, 2014.The facility policy and procedure titled, "Change of Condition Reporting" dated 05/2007, indicated, under "Acute Medical Change", 1.; "Any sudden or serious change in a resident's condition may...will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The ...nurse in charge will notify the physician." During a conversation with Patient 1's family member on October 1, 2014 at 10:30 AM, she stated Patient 1 was transported to an acute hospital, after her discharge from the facility on July 22, 2014. She further stated that the attending ER (Emergency Room) physician told her since the dislocation (left hip) had happened weeks ago, it would be difficult to "pop the hip back into place." The physician told her she should have brought her in sooner. Review of the hospital ER records showed, Patient 1 was admitted to the ER on July 22, 2014 at 2:45 PM. She was brought in by ambulance from the facility with a reported left hip fracture. Patient 1 was assessed by the ER physician and was found with "left hip with obvious deformity likely dislocated." The ER physician documented; "Spoke with (name of primary care physician) and agrees reducing hip in ER not appropriate considering the length of time hip has been dislocated ( greater than 2 weeks). (name of primary care physician) to admit and have the Orthopedic Doctor" Review of the hospital records showed a consultation report by the Orthopedic physician (bone doctor), dated July 23, 2014. The Orthopedic physician diagnosed Patient 1 with dislocated left hip prosthesis. The treatment plan for Patient 1 was to "attempt to reduce (procedure to set (reduce) a broken bone) the dislocation under anesthesia (gases to put the resident to sleep), but because of the length of time that the hip was dislocated, it may not be feasible for me to reduce the hip in a closed manner (reduce under anesthesia) and may require open reduction (making an incision in the skin and putting the fractured bones together and stabilizing with screws or plates or rods) of the hip dislocation."Review of the acute hospital records showed Patient 1 had the open reduction hip surgery on July 24, 2014 related to a dislocated left hip prosthesis. These violations had a direct relationship to the health, safety or security of the patients. |
| 240000289 |
Upland Rehabilitation And Care Center |
240012418 |
A |
1-Aug-16 |
1SD911 |
7539 |
REGULATION VIOLATION: (a) Nursing service shall include, but not limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. The facility failed to provide a safe environment to prevent accidents by not assessing for and identifying the hazards and risks associated with the improper use of full side rails for a patient who exhibited involuntary movements while in bed. Involuntary body movements caused Patient A's head to come completely through the vertical slats of the full side rail, and he was unable to remove his head without assistance. This could have resulted in serious injury, suffocation or death. Patient A was a 53 year old, male, who was admitted to the facility on May 12, 2015, with diagnoses which included: unspecified intellectual disabilities (below level intelligence), unspecified psychosis (severe mental disorder in which thought and emotions are so impaired that contact is lost with reality), and anxiety disorder (extreme fear or worry). During a routine observation on October 14, 2015 at 6:15 AM, Patient A was found with his head completely through the center portion of a full side rail. His head was dangling off of the mattress, and his entire body was on the bed. The side rail was observed to have no padding to prevent Patient A's head from going through the side rail. The side rail was observed to be a full side rail which had a latch at each end that was lifted up to let the side rail down. No facility staff was in the room. Patient A was completely still, eyes closed. During a review of the clinical record for Patient A, the minimum data set (MDS- an assessment tool) dated August 6, 2015, indicated that Patient A required extensive physical assistance from at least two persons for positioning, was non-ambulatory, and unable to get out of bed independently. The MDS indicated Patient A required at least two persons for transfer from bed to chair. There was no documentation of a restraint or side rail in use for Patient A. During an interview with a certified nursing assistant (CNA 1) on October 14, 2015 at 6:25 AM, CNA 1 stated that Patient A "moves around a lot in bed." When asked if Patient A had ever been found like this before, CNA 1 replied, "Yes, it has happened before. He usually starts moaning and wiggling around in bed at about 4:00 AM every day." There was no documented evidence that the previous incident had been reported. During an interview with a licensed vocational nurse (LVN 1), who discussed the situation with the CNA that found Patient A, on October 14, 2015 at 7:00 AM, LVN 1 stated, "The CNA told me that patient [Patient A] was found with his head between the rails... it is bad, really bad. I did a head to toe assessment and went to risk management." LVN 1 said it was identified as a non-safe incident, and it would be care planned and documented. There was no documented evidence found to indicate this had been done. During an observation of Patient A on October 14, 2015 at 7:30 AM, he was awake, eyes open. He was non-verbal, and was not interviewable. Patient A was noted to have contractures (a deformity or distortion) to both hands. During an interview with the Assistant Director of Nursing (ADON) on October 14, 2015, at 8:10 AM, she stated that CNA 1, the restorative nursing assistant (RNA- a CNA with specialized training), and LVN 1 had all reported to her, and to the Director of Nursing (DON) that Patient A was found with his head actually between the vertical slats of the full side rail. The ADON stated that she discussed the situation with the Director of Nurses (DON). The ADON stated that side rails can be used for mobility. The ADON also stated, "This patient does move around [in bed], but this has never happened to us before, a head getting stuck in the rail." During an interview with the minimum data set (MDS- an assessment tool) coordinator (MDS nurse) on October 14, 2015 at 8:40 AM, she stated that she did see Patient A with his head completely through the full side rails this morning, at 6:20 AM, when she entered the room at the same time the CNA and RNA had responded to the observation about Patient A's head being caught in the side rail. During an interview regarding the use of the full side rails for Patient A, the MDS nurse stated, "The CNA's just pull them [side rails] up." The MDS nurse verbalized that she did not know if Patient A was able to use his side rails to position himself in bed, and she stated "I don't know, I did his MDS back in August." During an interview with the Treatment Nurse on October 14, 2015 at 8:50 AM, she stated that Patient A is unable to hold the side rail by himself. She also stated that if she places his hand on the rail, he is still unable to hold on to it. The full side rails were measured by the treatment nurse, and the space between the vertical slats of the full rails was eight inches. Patient A's head was measured across the forehead from temple to temple, and measured six inches. The Treatment Nurse stated that Patient A's head would fit through the rail. During a review of the clinical record for Patient A, the Order Summary Report (doctor's orders), dated October 1 through October 31, 2015, reflected there was no order for side rails. There was no consent for side rails, and there was no side rail use mentioned in the care plan. During an interview with CNA 2 on October 14, 2015 at 8:50 AM, at Patient A's bedside, she stated, Patient A is unable hold onto the side rail, or use them for mobility. CNA 2 stated that the licensed nurses told her to put the side rails up to keep Patient A from getting up, or falling out of bed. The facility policy and procedure entitled "Side rails," dated August 2007 indicated, "It is the policy of this facility to utilize side rails as a mobility enabler or when needed/requested by the resident/resident surrogate to prevent falling out of bed. They are not used as a restraint." Under "Procedures" it states "1. Side rails are never to be used as a restraint. 2. If a resident needs extensive or total assist for bed mobility side rails may be used to prevent rolling out of bed. 5. When a resident has involuntary movements that could result in rolling off a bed - padding may be added to prevent injury." There was no documented evidence that Patient A was able to use the side rail to reposition himself, Patient A moved himself in a manner that could result in rolling out of bed, or that Patient A, his surrogate decision maker, or the physician had been contacted to discuss the use of any side rails. The facility failed to provide a safe environment to prevent accidents by not assessing for and identifying the hazards and risks associated with the improper use of full side rails for a patient who exhibited involuntary movements while in bed. The facility also failed to follow their policy and procedure for the use of side rails. These failures resulted in Patient A's head to coming completely through the vertical slats of the full side rails. These facility failures presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result. |
| 240000289 |
Upland Rehabilitation And Care Center |
240012618 |
B |
5-Oct-16 |
1SD911 |
3967 |
REGULATION VIOLATION Patients? Rights 72527(a)(10) (a)Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. The facility shall establish and implement written policies and procedures which include these rights and shall make a copy of these policies available to the patient and to any representative of the patient. The policies shall be accessible to the public upon request. Patients shall have the right: (10) To be free from mental and physical abuse. FINDINGS The facility violated the above regulation by failing to: Protect one of 18 sampled patients (Patient A) from verbal abuse by a staff member when the staff member refused to put Patient A back to bed after Patient A?s therapy session and spoke to Patient A in a verbally abrasive manner. During an observation on October 13, 2015 at 12:12 PM, while standing outside of Patient A?s room, a Physical Therapy Aide (PTA1) was overheard to have been verbally abrasive to Patient A. After looking into the room, an observation was made of Patient A sitting in her wheelchair at the bedside, with the PTA 1 standing over Patient A. Patient A?s roommate was in the room. Patient A was overheard requesting the PTA 1 to assist her back to bed and complaining of pain and nausea. The PTA 1 was overheard refusing to put Patient A back to bed and stated in a loud, verbally abrasive voice while standing over Patient A, ?I am not a pushover and I am not going to put up with this.? The PTA 1 left Patient A?s room. Upon entering Patient A?s room on October 13, 2015 at 12:15 PM, Patient A was observed sitting up in her wheelchair and was visibly shaking. During a concurrent interview with Patient A, Patient A stated, ?I don?t? like him (PTA 1), he is pushy. I have to put up with it. He talks down to me like that every day. I like his partner better, he is more understanding.? A concurrent interview was conducted with Patient A?s roommate, (Patient B) who was also present when the PTA 1 was in the room. Patient B stated, ?He talks down to her like that every day.? During an interview on October 13, 2015 at 12:20 PM, the Physical Therapy Director (PTD) stated, ?A therapist should be encouraging when they speak to a patient. The PTD stated the statement used by the PTA 1, ?I am not a push over and I am not going to put up with this?, was not encouraging. ? The Physical Therapy Director indicated that she was aware of the abrasive manner PTA 1 used when he spoke to Patient A but that she had witnessed the behavior earlier that morning in the Physical Therapy Room. The PTD stated she planned to meet with PTA 1 on how to communicate with Patient A. During an interview with PTA 1 on October 13, 2015 at 3:00 PM, to discuss the abrasive manner he was witnessed using with Patient A, the PTA 1 stated, ?I have had my most success with this approach. We are going to battle it out a little bit. It is a unique approach. With (Patient A?s name) it?s a little bit of locking horns.? The PTA 1 further stated, ?No, there is no care plan that states to be forceful.? PTA 1 stated, ?Looking back, I probably should not have been speaking to her in this way.? During an interview with the Certified Occupational Therapy Aide (COTA) on October 13, 2015 at 3:15 PM, the COTA stated, ?My approach is to ease Patient A into it (therapy), I know how she responds.? During a review of the facility policy and procedure entitled, ?Policy/Procedure-Nursing Administration,? dated April 2013, the policy and procedure set forth the following: ?The employees of our facility are mandatory reporters and will take action to protect and prevent abuse and neglect from occurring within the facility by: Supervision of staff to identify inappropriate behaviors (i.e., derogatory language?).? The violation was determined to cause, or under circumstances likely to cause significant humiliation, indignity, anxiety, or other emotional trauma to the patient. |
| 970000135 |
UNIVERSITY PARK HEALTHCARE CENTER |
940009529 |
A |
19-Nov-12 |
PCS411 |
9905 |
483.25(g)(2)(A) 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, it possible, normal eating skills.On 12/1/11, at 8:15 a.m., an unannounced visit was made to the facility to investigate an entity reported incident regarding Resident 1's gastrostomy tube (GT - a tube surgically inserted into the stomach through the skin and the stomach wall to provide nutrition and medication) that was pulled out on 11/5/11, and replaced in order to complete the feeding. On the same day while at the dialysis center, Resident 1 became less responsive and was transferred to a general acute care hospital (GACH).Based on interview and record review, the facility failed to ensure Resident 1, who was fed by a GT which had been inserted for the first time on 10/26/11, received the appropriate treatment and services to prevent complications by failing to: Implement the facility?s policy and procedure that indicated to insert the GT only as per physician?s order, not to reinsert a new GT (less than four weeks old) and not to replace a PEG [percutaneous (procedure performed through the skin) endoscopic gastrostomy] tube. On 11/5/11, at 6:15 a.m., after the resident?s GT was pulled out and 10 days after the GT surgical insertion, Registered Nurse 1 (RN 1), without a physician?s order, reinserted a new GT and resumed the feeding formula. On the same day, around 2 p.m., the resident developed an altered level of consciousness and required transfer to GACH 2 via paramedics. The resident was found to have the GT tip outside the stomach, developed peritonitis (inflammation of the membrane which lines the inside of the abdomen and all of the internal organs), had an intra-abdominal abscess (collection of pus) and sepsis (potentially life-threatening complication of an infection). The resident remained in GACH 2 until 11/20/11, where he twice required drainage of abdominal abscess. On 11/20/11, the resident was transferred to a skilled nursing facility; however, he could not be admitted because he was short of breath upon arrival. Paramedics then transferred the resident to GACH 2 where he expired on 11/23/11.On 12/1/11, a review of Resident 1's clinical record revealed the resident was initially admitted to the facility from GACH 1 on 10/27/11, with diagnoses including dysphagia (difficulty swallowing), GT, diabetes mellitus, end stage renal disease, hemodialysis (procedure for removing metabolic waste products or toxic substances from the bloodstream by dialysis machine) treatment, status post cardiac arrest and schizophrenia (is a psychotic disorder marked by severely impaired thinking, emotions, and behaviors). According to the clinical record from the transferring hospital (GACH 1), where the resident stayed from 9/16/11 to 10/27/11, the resident required on 10/26/11, a placement of a PEG tube due to difficulty with swallowing. The Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 11/3/11, indicated the resident was severely impaired in his cognitive skills (never/rarely made decisions), had communication deficit, required extensive to total assistance with all of his activities of daily living and received nutrition only through the GT.Upon admission on 10/27/11, the attending physician ordered the feeding formula Novasource Renal at 75 cubic centimeters (cc) per hour to provide 1200 cc, 1200 kilocalories (kcal) in 16 hours per day, by the way of a feeding pump. The physician ordered to flush the GT with 370 cc of water every six hours. All medications were ordered to be administered through the GT. The physician also ordered hemodialysis treatment three times a week, on Tuesdays, Thursdays and Saturdays, at an outpatient dialysis center beginning at 4:30 p.m. The physician's order did not include orders to reinsert or replace the GT if it was pulled out or became dislodged. According to the 11 p.m. to 7 a.m. shift nursing note and a Change of Condition Assessment form dated 11/5/11, RN 1 documented the resident's GT was pulled out, found on the floor at 6:15 a.m. and the GT site was slightly bleeding. The GT was reinserted, the resident tolerated the procedure, a dressing was applied, the GT was patent and the feeding was resumed. RN 1 further documented he called the attending physician at 6:45 a.m. and left a message. According to the nursing note, on 11/5/11, timed at 3 p.m., the resident went to dialysis in stable condition. The nursing note entry dated 11/5/11, timed at 3:20 p.m., indicated the dialysis center transferred the resident to a hospital (GACH 2) due to unresponsiveness. A review of the clinical record from GACH 2 revealed the resident arrived to the emergency department on 11/5/11, at 2:15 p.m., with altered mental status. At the same time, the x-ray result shows right lower lobe pneumonia. On 11/6/11, a computed tomography (CT) of the abdomen and pelvis with contrast indicated the GT was outside of the antrum (initial portion) of the stomach. There was some small loculated (divided into small cavities or compartments) fluid collections near the tip of the GT and multiple small pockets of free intraperitoneal (within the peritoneal cavity) gas. On the same day, due to peritonitis and dislodgement of the GT, the resident underwent an exploratory laparotomy (surgical incision into the abdominal cavity through the flank or, more generally, through any part of the abdominal wall). He required drainage of intraperitoneal abscess and tube feeds, a gastrorrhaphy (suture of the stomach) and a new GT. On 11/14/11, due to continued intraperitoneal fluid collection and the resident not being a candidate for another laparotomy, he underwent a CT-guided fluid and peritoneal abscess drainage followed by a wound VAC (vacuum assisted closure). The edges of the wound are made airtight with foam and a dressing, and a tube attached to a vacuum is placed in the wound. Infectious materials and other fluids are then sucked out of the wound. On 11/20/11, the resident was transferred to another skilled nursing facility for continued care with IV antibiotics and wound VAC. A review of the receiving skilled nursing facility documentation revealed the resident was unable to be admitted to the facility on 11/20/11, because he arrived in an unstable condition. Paramedics were required to transfer the resident to a nearby hospital (GACH 3) due to shortness of breath where the resident expired on 11/23/11.According to the Certificate of Death, the resident expired on 11/23/11, at 1:55 p.m., with the cause of death indicating cardiopulmonary arrest, sepsis and pneumonia. On 12/1/11 at 11:20 a.m., during an interview, Licensed Vocational Nurse 1 (LVN 1), who was the medication nurse on 11/5/11, 7 a.m. to 3 p.m. shift, stated he gave the resident the medications via GT and he checked the GT for placement and residual. LVN 1 also stated the resident was, "Okay", when he left for dialysis. On 12/1/11, at 11:30 a.m., during an interview, RN 1 confirmed he replaced the resident's GT using a house supplied GT (Corflo brand) size 16 French to prevent closing of the stoma. RN 1 stated, ?He checked patency and air and was okay.? RN 1 also indicated there was no problem with the GT placement. RN 1 further stated he called the physician and left a message, however, the physician did not return the call. A review of the personnel file revealed RN 1 was hired on 8/19/96, with the last enteral feeding competency check done on 8/19/10. According to the facility's policy and procedure on Gastrointestinal Tube Change and Reinsertion dated 12/2000, gastrointestinal tubes will be changed and reinserted, per physician's order, in residents with established tracks in order to maintain patency for nutritional maintenance. The procedures indicated to obtain a physician's order. The policy further noted it was recommended a new GT (less than four weeks old) not to be reinserted by facility licensed nurses and PEG tubes should not be removed or replaced by a licensed nurse at the facility.The facility failed to ensure Resident 1, who was fed by a GT which had been inserted for the first time on 10/26/11, received the appropriate treatment and services to prevent complications by failing to: Implement the facility?s policy and procedure that indicated to insert the GT only as per physician?s order, not to reinsert a new GT (less than four weeks old) and not to replace a PEG [percutaneous (procedure performed through the skin) endoscopic gastrostomy] tube. On 11/5/11, at 6:15 a.m., after the resident?s GT was pulled out and 10 days after the GT surgical insertion, Registered Nurse 1 (RN 1), without a physician?s order, reinserted a new GT and resumed the feeding formula. On the same day, around 2 p.m., the resident developed an altered level of consciousness and required transfer to GACH 2 via paramedics. The resident was found to have the GT tip outside the stomach, developed peritonitis (inflammation of the membrane which lines the inside of the abdomen and all of the internal organs), had an intra-abdominal abscess (collection of pus) and sepsis (potentially life-threatening complication of an infection). The resident remained in GACH 2 until 11/20/11, where he twice required drainage of abdominal abscess. On 11/20/11, the resident was transferred to a skilled nursing facility; however, he could not be admitted because he was short of breath upon arrival. Paramedics then transferred the resident to GACH 2 where he expired on 11/23/11. 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 to Resident 1. |
| 970000135 |
UNIVERSITY PARK HEALTHCARE CENTER |
940011762 |
B |
30-Sep-15 |
6Z5X11 |
6010 |
F226 ?483.13(c) DEVELOPMENT 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 by not: 1. Reporting the alleged sexual abuse regarding Resident 1 to the Department. 2. Implementing its policy regarding reporting all allegations of abuse within 24 hours. This failure of the facility not following its policy and procedure put Resident 1 and other residents at risk for abuse not reported and thoroughly investigated.The Department received a complaint on 2/17/15, alleging a resident (Resident 1) complained her mouth was hurting after a certified nurse assistant (CNA1) made her perform oral sex on him. The complainant called the police and facility and reported it.On 2/17/15, at 12:45 p.m., an unannounced complaint investigation was conducted. During the facility?s observation, a concurrent interview was conducted with the director of nursing (DON), who stated on Friday, 2/13/15, Resident 1?s family member complained about an incident of an alleged sexual abuse. The DON stated the police was also investigating the alleged incident, and the resident was transferred to a general acute care hospital (GACH) for an evaluation. On 2/17/15, at 1:45 p.m., during an interview, Resident 2 (Resident 1?s roommate) stated on 2/13/15, after CNA 1 transferred Resident 1 from the wheelchair to the bed, CNA 1 turned off the light and left the room. Resident 2 stated after CNA 1 left the room, she heard Resident 1 call her family and state that CNA 1 made her performed oral sex on him. Resident 2 stated that evening of the alleged incident (2/13/15), Resident 1 changed her story a couple times. Resident 2 stated Resident 1 told her family member that CNA 1 forced her to performed oral sex on him, but when the police interviewed the resident she stated the incident did not occur.A review of Resident 1's clinical record indicated the resident was a 68 year-old female who was admitted to the facility on 10/30/14, and re-admitted on 2/07/15. The resident?s diagnosis included dementia (a decline in mental ability severe enough to interfere with daily life) with behavior disturbances.A review of a Minimum Data Set (MDS), an assessment and care screening tool, dated 2/12/15, indicated Resident 1 was alert and oriented, but required extensive assistance in all activities of daily living, except eating, which the resident required only supervision. On 2/17/15, at 3:40 p.m., during an interview, CNA 1 stated on 2/13/15, which was a Friday afternoon, after he changed Resident 1 he left the room to take care of other residents, but came back into the resident?s room to empty the commode. CNA 1 stated when Resident 1 saw him she asked for some mouth wash and complained she had a cough and a sore throat. CNA 1 stated he gave the mouth wash to the resident and reported Resident 1?s complaint of coughing with a sore throat to the licensed nurse. CNA 1 stated at approximately 10 p.m., that night 2/13/15, the licensed nurse called all the CNAs to the nurse?s station and told them Resident 1?s family member had made a complaint that CNA 1 had put his private part into the resident?s mouth. However, CNA 1 denied the sexual abuse allegation occurring.At 4:20 p.m., on 2/17/15, during an interview, CNA 2 stated after she learned about the alleged sexual abuse, she went into Resident 1?s room and spoke to the resident in Spanish. CNA 2 stated she asked the resident if CNA 1 put his private part in her face and or mouth. CNA 2 stated Resident 1 looked confused and stated, ?Nothing happened, I think, I was dreaming."CNA 2 stated Resident 1 requested to be transfer to the GACH for an evaluation due to the mouth pain. A review of the GACH? record, dated 2/15/15, titled, ? Psychological Consultation,? indicated Resident 1 was admitted to the GACH for a workup, management of a sore throat, and to rule-out a sexual assault. The record indicated when the resident was asked about the possible sexual assault, Resident 1 indicated at one of the places, one of the nurses lowered his pants, and asked her to fondle his penis. Resident 1 stated, "I did consent" but stated she did not like the experience, but consented to it. According to the record, Resident 1 had changed the story a couple of times, indicating at one point, it was not with the staff, but with another resident. The report concluded the findings taken were suggestive of severe cognitive and intellectual impairments consistent with impression of atypical bipolar disorder (different personality types), organic mood disorder (mood changed due to physiological problem with the brain), dementia of the cerebrovascular type (blockage of blood flow to part of the brain stopped) with moderate behavioral disturbances, cognitive impairment associated with history of two cerebrovascular accidents (stroke).On 7/2/15 at 10:30 a.m., during an interview, a registered nurse supervisor stated the facility?s staff did not report the alleged sexual abuse incident to the Department because the resident?s family member had reported the complaint to the police and Resident 1 told the police the incident did not occur. However, a review of an undated facility's policy and procedure titled, " Policy on Abuse Prevention and Mandated Reporting," indicated the facility shall ensure all incidents of alleged abuse or suspected abuse be reported to the Department of Public Health as soon as practically possible, not to exceed 24 hours, failure to report is subject to class B citation. The facility failed by not: 1. Reporting an alleged sexual abuse regarding Resident 1 to the Department. 2. Implementing its policy regarding reporting all allegations of abuse within 24 hours. The above violation had a direct or immediate relationship to the health, safety, or security of Resident 1. |
| 970000135 |
UNIVERSITY PARK HEALTHCARE CENTER |
940013431 |
A |
24-Aug-17 |
4RQ211 |
15519 |
F 309 ?483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices.
The facility failed to provide each resident with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, including but not limited to:
1. Failure to implement Resident 1's plan of care and the wound care specialist recommendations for wound care.
2. Failure to assess, monitor, and report the progressions of Resident 1?s wounds.
3. Failure to promptly address Resident 1?s change in condition, as per the facility?s policy.
These deficient practices resulted in Resident 1?s wound worsening and becoming infected requiring a transfer and admission to a general acute care hospital (GACH) for over a month, being intubated (placement of a flexible plastic tube into the trachea [windpipe] to maintain an open airway) with ventilator (an appliance for artificial respiration; a respirator) support for breathing, IV (into the vein) antibiotics, ICU care (intensive care), pain management, and wound debridement.
a.A review of Resident 1?s Admission Record Face Sheet, indicated the resident was a 68 year-old male, who was originally admitted to the facility on XXXXXXX15, and readmitted on XXXXXXX16. Resident 1?s diagnoses included sepsis (a life-threatening complication of an infection), peripheral vascular disease ([PVD] disorder of the circulatory system outside of the brain and heart) with a non-pressure chronic ulcer of the right heel and midfoot (the arch of the foot), gangrene (dead tissue caused by an infection or lack of blood flow), osteomyelitis (inflammation of the bone caused by infection), and Type 2 diabetes mellitus (blood sugar levels higher than normal).
A review of Resident 1's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 5/4/17, indicated the resident was unable to report the correct year, month, and day of the week. The MDS indicated the resident required extensive assistance (resident involved in the activity, while staff provides weight-bearing support), for bed mobility, transferring, toilet use, and personal hygiene. The MDS indicated Resident 1 had impairment to both sides of the lower extremity.
A review of Resident 1?s wound consult progress note titled, ?Progress Note Details,? dated 12/13/16, indicated for the staff to inform the primary care physician (PCP) if the wounds worsen or if the resident develops a fever.
A review of Resident 1?s Care Plan titled, ?Venous Stasis (poor blood circulation in the legs) of the Right Medial Ankle, Related to PVD,? dated 1/22/16, indicated the staff?s interventions included to monitor, document, and report to the physician as needed (PRN), for signs and symptoms of infection, such as green drainage, foul odor, redness, swelling, red lines on the wound, excessive pain, and/or fever.
A review of Resident 1?s IDT?s ([interdisciplinary team] acoordinated group of experts from several different fields who work together toward a common resident goal) Wound Management Update Record, dated 2/10/17, indicated the resident had a right lower extremity medial vascular wound, with measurements of five centimeters (cm.) in length, five cm. in width, and with an unable to determine (UTD) depth. The area of the IDT?s record that indicated ?Pressure Management,? for recommendations for the care of Resident 1?s wounds was left blank.
A review of Resident 1?s IDT?s record, dated 3/3/17, indicated the resident had a right lower extremity medial vascular wound, with measurements of 12.8 cm in length, nine cm in width, and UTD depth. The area of the record that indicated ?Pressure Management,? for recommendations for the care of Resident 1?s wounds was left blank.
A review of Resident 1?s Pressure Ulcer (a localized injury to the skin or underlying tissue, usually over a bony prominence, as a result of unrelieved pressure) Weekly Management Record, for the months of April and May 2017, indicated the resident had a right lower extremity medial wound. The record indicated the measurement of the wound was three centimeters (cm) in length, two cm in width, and UTD depth. The record indicated the wound was unstageable (full thickness tissue loss in which the base of the ulcer is completely covered), with 100 percent (%) eschar (a dry, dark scab or falling away of dead skin) and slough (dead subcutaneous tissue in a wound). The record indicated the wound care treatment that was ordered by the physician on 1/22/17, included using one-half strength of Dakin?s Solution ([diluted bleach] used to treat and decrease irritation and kill germ growth in wounds), with a moistened gauze.
A review of Resident 1?s Care Plan titled, ?Venous Stasis of the Right Medial Ankle, Related to PVD,? dated 1/22/16, indicated the staff?s intervention to check the dorsalis pedis ?pedal? pulses (the artery located in the upper surface of the foot).
A review of the facility?s Policy and Procedure (P/P) titled, ?Pressure Ulcers/Skin Breakdown-Clinical Protocol,? revision dated 10/2010, indicated the nurse assesses, documents, and reports vital signs, pain assessment, and a full assessment of pressure ulcer including location, stage, length, width, depth, and presence of exudates (a mass of cells and fluid that has seeped out of blood vessels or an organ, especially during an infection) or necrotic tissue. The P/P indicated during resident visits, the physician would evaluate and document the progress of wound healing-especially those with complicated, extensive, or non-healing wounds. The P/P indicated the physician would help the staff review and modify the care plan as appropriate.
On 6/21/17, at 4:23 p.m., during a concurrent interview and record review, the DON stated the wound care specialist stopped evaluating Resident 1?s right lower extremity wounds, and there were no changes in wound care treatment since 12/2016. The DON stated Resident 1 had an ongoing infection on the right lower extremity. The DON stated if the wound progressed or remained the same, the nurses are responsible to ensure care plans are reviewed and revised to meet the resident?s goals.
On 6/23/17 at 2 p.m., during a telephone interview, Licensed Vocational Nurse 2 (LVN 2) stated Resident 1 had multiple wounds on different sites of the right lower extremity that remained the same, without improvement. LVN 2 stated Resident 1 had bone exposed and an odorous smell on the right lower extremity that should have been documented as part of the resident?s skin assessment. LVN 2 was asked if the resident was receiving wound care by a wound care specialist and LVN 2 stated the resident was no longer being treated by the wound care specialist.
On 7/6/17 at 10:52 a.m., during a telephone interview and concurrent record review, the DON stated for Resident 1?s Pressure Ulcer Management Record, for the months of April and May 2017, the record was incomplete and did not indicate an area to document signs and symptoms of infection (odor and pain). The DON stated documenting odor and pain was part of the staff?s intervention as indicated on the resident?s plan of care. The DON stated the treatment nurses should have used the ?Wound Evaluation Flow Sheet,? for the months of April and May 2017 to assess Resident 1?s wound.
On 8/1/17, at 3:19 p.m., during a telephone interview, LVN 4 stated the nurses are responsible to assess the resident?s pedal pulses, but stated she does not unless there was a need to do so. LVN 4 stated a resident?s pedal pulse should be assessed for a resident with osteomyelitis (bone infection).
On 8/1/17, at 3:20 p.m., during a telephone interview, the DON stated the treatment nurses were expected to check the resident?s pedal pulses as part of their wound care assessment and if indicated as an intervention on the resident?s care plan.
b. A review of Resident 1?s Change of Condition Record, dated 5/19/17, and timed at 3:21 p.m., indicated Resident 1 was transferred to the GACH on XXXXXXX17, at 7:30 a.m., for low blood oxygen saturation at 70 percent [%] (an estimate of the amount of oxygen in the blood [normal reference range [NRR]=94 to 100 percent). The record indicated Resident 1 was administered two liters of oxygen via nasal cannula ([N/C] a device used to deliver supplemental oxygen or airflow). The record indicated the resident?s blood pressure was recorded at 141/69 millimeter of mercury ([mmhg] NRR=120/80), pulse at 94 beats per minute (NRR=60 to 100), and Resident 1 exhibited labored breathing (an abnormal respiration characterized by much effort to breathe). The record indicated there was no respiration rate and temperature documented.
A review of the facility?s Policy and Procedure titled, ?Change in a Resident?s Condition or Status,? with a revision dated of 4/2011, indicated the charge nurse or nurse supervisor will record in the resident?s medical record information relative to changes in the resident?s medical condition or status.
A review of Resident 1?s Emergency Room (ER) documentation Record, dated 5/19/17, and timed at 8:27 a.m., indicated per the emergency medical services (EMS [paramedics]), Resident 1 had 15 minutes of respiratory distress after staff from the facility checked on him that morning, with low oxygen saturation levels The record indicated Resident 1 was febrile ([fever] elevated temperature) with a temperature of 38.6 degrees Celsius [C] (101.5 degrees Fahrenheit (F) [NRR is 98.6 degrees F or 37 degrees C). The ER note indicated the resident had multiple possible sources of infection, which included the right lower extremity skin osteomyelitis.
A review of Resident 1?s Cardiology (a physician who specialized in heart conditions) Consultation Note, from the GACH, dated 5/19/17, indicated the resident was found to be in respiratory distress for about 15 minutes before the EMS was called to the facility. The note indicated Resident 1 was intubated upon arrival. The note indicated the resident was hypertensive (high blood pressure), with a blood pressure of more than 200/100 mmhg. The physician also documented Resident 1 did not have dorsal pedal (a blood vessel of the lower limb that carries oxygenated blood to the dorsal surface of the foot) pulses on the right lower extremity.
A review of Resident 1?s Orthopedic (a physician who specializes in conditions of the bones) Consultation Notes, from the GACH, dated 5/20/17, indicated the resident?s right lower extremity had a diffused necrotic (death of a cell) area along the medial aspect of the foot that was foul smelling. The note indicated the resident?s pulse on the right lower extremity were weak.
A review of Resident 1?s Vascular Surgery Consultation Progress Note, dated 5/22/17, indicated the resident had a large medial malleolar (a bony projection on either side of the ankle) ulcer that was foul smelling.
A review of Resident 1?s GACH ?History and Physical Reports,? dated 6/24/17, and timed at 3:31 p.m., indicated the resident received Cefepime and Clindamycin (antibiotics), IV (intravenous,) from 5/24/17 to 6/12/17 and Vancomycin (antibiotic) IV from 6/4/17 to 6/8/17.
On 5/26/17, at 3:35 p.m., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 appeared tired, with shortness of breath prior to being transferred to the hospital on 5/19/17. LVN 1 stated possible signs and symptoms of sepsis are elevated temperature, low blood oxygen levels, and rapid breathing.
On 6/19/17, at 8:05 a.m., during a telephone interview, the GACH?s physician (Physician 1) stated Resident 1 presented to the GACH on 5/19/17 in with respiratory distress, with a fever and high blood pressure, and with an increased white blood cell count ([WBC] when elevated usually indicative of an infection).
On 6/19/17, at 8:35 a.m., during a telephone interview, LVN 4 stated Resident 1 had difficulty breathing, and was breathing rapidly. LVN 4 stated, ?We had to take the vital signs to know what was going on because he looked ok.? LVN 4 stated she was checking Resident 1?s vital signs with LVN 1 in the room and thought LVN 1 was recording the vital signs, but the temperature and respiration rate were not recorded, but should have been documented on the Change of Condition Record.
On 7/5/17, at 4:21 p.m., during a telephone interview and a concurrent record review, the DON stated she was unable to determine the condition of Resident 1, on 5/18/17, during the night shift (11 p.m. to 7 a.m.), because there was no documentation on the resident?s progress notes, indicating Resident 1?s condition prior to the change of condition on 5/19/17, at 7:15 a.m.
On 8/1/17 at 3:19 p.m., during a telephone interview, a licensed vocational nurse (LVN 5) stated if a resident had low oxygen saturation, she would place the resident on at least four to six liters of oxygen per mask in order to increase the oxygen saturation. LVN 5 stated a physician?s order was not required in order to administer a higher oxygen concentration rate in order to save the resident?s life. However, a review of the facility?s policy titled, ?Oxygen Administration,? with a revision date of 10/2010, indicated to verify there was a physician?s order before the oxygen administration.
At 3:20 p.m., on 8/1/17, during a telephone interview, the director of nursing (DON) stated if resident has an oxygen saturation of 70 %, the licensed nurse should administer 10 to 15 liters of oxygen, on a non-rebreather mask (a device used to deliver high concentrations of oxygen) to the resident, and stabilize the oxygen saturation until the paramedics arrive. The DON stated an oxygen saturation of 70 % is an emergent and critical situation and a physician?s order is not required to administer oxygen.
On 8/2/17, at 3:07 p.m., during a telephone interview, LVN 4 stated when Resident 1 informed LVN 4 of feeling shortness of breath she checked the resident?s oxygen saturation and was critically low. LVN 4 stated she administered two liters of oxygen via nasal cannula to the resident. LVN 4 stated she was unsure if the resident had a history of COPD (chronic obstructive pulmonary disease), so she did not increase the oxygen concentration to more than two liters. LVN 4 stated Resident 1?s oxygen saturation level never increased, and remained critically low.
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 implement Resident 1's plan of care and the wound care specialist recommendations for wound care.
2. Failure to assess, monitor, and report the progression of Resident 1?s wounds.
3. Failure to promptly address Resident 1?s change in condition, as per the facility?s policy.
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 970000135 |
UNIVERSITY PARK HEALTHCARE CENTER |
940013432 |
A |
24-Aug-17 |
4RQ211 |
16148 |
F315 ?483.25(e) Incontinence
(2) A resident with urinary incontinence, based on the resident?s comprehensive assessment, the facility must ensure that-
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.
The facility failed to provide each resident with the necessary care and services in accordance with the comprehensive assessment and plan of care to ensure residents, who had urinary catheters, received appropriate treatment and services to prevent urinary tract infections (UTI), including but not limited to:
1. Failure to accurately assess and monitor urine characteristics and report abnormalities to the physician as per the residents? plan of care and the facility?s policy.
2. Failure to implement the resident?s care plan in the prevention of UTIs.
3. Failure to ensure the resident?s urinary catheter tubing was not kinked and the urinary bag was not placed above the bladder as per the facility?s policy.
These deficient practices resulted in the reoccurrence of UTIs for both Residents 2 and 3, requiring IV (into the vein) antibiotics (medications to treat infections), pain medications, and several transfers to a general acute care hospital (GACH) for UTI treatments. Resident 3 had three transfers to the hospital in less than 40 days related to UTIs, the indwelling urinary drainage bag was observed raised above the resident's bladder, during the resident's wound care treatment.
a. A review of Resident 2's Admission Record Face Sheet indicated the resident was 73 year-old male who was admitted to the facility on XXXXXXX17. Resident 2?s diagnoses included acute kidney failure ([AKf], also known as acute renal failure, a condition in which the kidneys suddenly cannot filter waste from the blood), benign prostatic hyperplasia ([BPH], an age-associated prostate gland [a male reproductive organ, surrounding the urethra] enlargement that can cause urination difficulty) with lower urinary tract symptoms (problems with the bladder, prostate, and urethra, associated with voiding or storage of urine), and Vancomycin Resistant Enterococcus ([VRE], a bacteria that has developed resistance to many antibiotics [medications used to kill bacteria and fight infections]) in the urine.
A review of Resident 2's Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 5/11/17, indicated Resident 2 had limited ability to make concrete requests, and responded adequately to simple and direct communication only. The MDS indicated Resident 2 was not able to report the correct year, month and day of the week. The MDS indicated Resident 2 required extensive assistance (staff providing weight-bearing support) for toilet use and personal hygiene. The MDS indicated Resident 2 had an indwelling urinary catheter and was always incontinent of bowel (lack of control).
A review of Resident 2's Admission Nursing Data Tool, dated 5/5/17, indicated the resident had a suprapubic catheter (a surgical tube through the stomach placed in the bladder for drainage of urine) present on admission.
A review of Resident 2's Physician?s Order for Infusion Therapy Record, dated 5/4/17, indicated to administer Zosyn (an antibiotic), 3.375 grams (gm) via IV every 12 hours for five days, for the diagnosis of VRE in the urine.
A review of Resident 2's Physician's Order Summary Report, for the month of May 2017, indicated to monitor, and document the resident's indwelling urinary catheter output for color and consistently every day shift, for suprapubic catheter use.
A review of Resident 2's urinalysis ([UA] test used to test for drugs or diseases) laboratory results, dated, 5/16/17, timed at 7:10 a.m., indicated there was blood, bacteria, white blood cells ([WBC], cells of the immune system involved in protecting the body against infectious disease and foreign invaders), red blood cells ([RBC], transports oxygen and carbon dioxide to and from the tissues), in the urine. The UA had a cloudy appearance and was positive for Leukocyte Esterase (an enzyme produced by WBC, indicative of an infection or inflammation) in the urine.
A review of Resident 2's Physician?s Order for Infusion Therapy Record, dated 5/19/17, indicated to administer Amikacin (an antibiotic), 500 milligrams (mg) daily for five days, for the diagnosis of UTI.
A review of Resident 2's Treatment Administration Record (TAR), for the month of May 2017, indicated to monitor and document the resident's urinary catheter output for color and consistently every day shift, as follows: "C" for clear, "P" for pus (a thick yellow or green opaque liquid produced in infected tissue, consisting of dead WBC and bacteria), "S" for sediment (any matter transported by fluid flow, eventually deposited on the bottom of liquid), "M" for mucoid (thick, gelatinous secretion), "A" for amber, "H" for hematuria (blood in the urine), and "O" for orange. The TAR indicated on 5/26/17, during the 7 a.m. to 3 p.m. shift (dayshift), Resident 2?s urine color was amber and clear.
A review of Resident 2's Care Plan titled, "Resident has Urinary Suprapubic Catheter, Related to BPH, at Risk for UTI," initiated on 5/26/17, and revised on 5/31/17, indicated staff?s interventions included to monitor for signs and symptoms of UTI, position the drainage system (tubing and collection bag) to facilitate flow of urine, and empty the urinary drainage bag when one half to two thirds full, or every three to six hours.
A review of Resident 2's Change of Condition Record, dated 5/27/17, and timed at 11 a.m., indicated the resident had a small blood clot in the suprapubic catheter.
A review of Resident 2's Physician?s Order, dated 5/27/17, and timed at 5:29 p.m., indicated to transfer the resident to the GACH for hematuria (blood in the urine) and clots for evaluation and treatment, and to change the resident's suprapubic catheter. Resident 2 returned to facility on XXXXXXX17 after receiving treatment for UTI.
A review of Resident 2's GACH?s UA and Urine Culture ([C/S] a urine test to detect bacteria in the urine for appropriate antibiotic treatment) Report, dated 5/27/17, indicated the resident's urine color was red, cloudy, contained large amounts of blood, protein, WBCs, RBCs, and Leukocyte Esterase.
A review of Resident 2's GACH?s Physician?s Progress Note, titled "Final report," dated 5/30/17 and timed at 2:08 p.m. indicated the resident had a diagnosis of hematuria and UTI.
A review of Resident 2's Physician?s Order Summary Report, dated 5/31/17, indicated to administer Ceftriaxone (an antibiotic), via IV, for four days, for the treatment of UTI, due to a multi-drug resistant Escherichia coli ([MDRE], an organism with significant resistance to two or more antibiotics).
On 5/26/17, at 12:40 p.m., during an observation, Resident 2 was observed with blood-tinged urine, and small, bloody clots inside the suprapubic catheter tubing. The tubing was observed kinked proximal to the urinary drainage bag.
On 5/26/17, at 2:36 p.m., during an observation and interview, Certified Nursing Assistant 1 (CNA 1) was observed emptying Resident 2's urine from the urinary drainage bag into a container. CNA 1 stated Resident 2's urinary drainage bag was last emptied at 8 a.m. that morning. CNA 1 stated the charge nurse was not notified of the resident's urine characteristics because the resident's urine usually appeared a little bloody. CNA 1 stated the color of Resident 2's urine appeared "a little lighter than in the morning." Resident 2's suprapubic catheter tubing was wrapped around the left bed rail, kinked, and the urinary drainage bag was touching the floor. Licensed Vocational Nurse 1 (LVN 1) stated Resident 2's urine has been bloody with sediment since admission. LVN 1 stated, "I think the color of the urine actually improved." LVN 1 stated the treatment nurse usually flushes the indwelling urinary catheter tubing as prescribed by the physician.
On 5/26/17, at 3 p.m., during an interview, LVN 2, the Treatment Nurse, stated she did not yet see Resident 2, or perform any treatment on the resident during her shift.
On 5/26/17, at 3:48 p.m., during an interview and record review, LVN 2 stated she documented Resident 2's urine color as amber and clear on the TAR, dated 5/26/17, during the 7 a.m. to 3 p.m. shift, prior to assessing or performing treatment on the resident. LVN 2 verified that her documentation was inaccurate and that there were clots in Resident 2?s urine. LVN stat she needed to call the physician.
On 6/21/17 at 1:30 p.m., during an interview, CNA 2 stated the urinary bags of residents with indwelling urinary catheters, are emptied two to three times a shift. CNA 2 stated the importance of maintaining the urinary bag in a low position, and not touching the floor. CNA 2 stated if the characteristics and color of the urine looked abnormal she would notify the charge nurse immediately.
On 6/21/17, at 2 p.m., during an interview, LVN 3 stated licensed nurses are responsible to monitor the urinary output and urine characteristics of the resident?s urine. LVN 3 stated blood or sediment in the urine are abnormal and should be reported to the physician immediately. LVN 3 stated licensed nurses should frequently check the tubing of the indwelling urinary catheters to ensure the tubing was free from twists or kinks.
On 6/21/17, at 4:23 p.m., during a telephone interview, the Director of Nurses (DON) stated the treatment nurses were responsible to ensure that treatments orders are completed for each resident. The DON stated checking on the resident routinely was the duty of all staff members. The DON stated documentation on the resident's medical record should be done after performing the treatment, and not prior.
On 6/21/17, at 5 p.m., during a telephone interview, the DON stated Resident 2's care plan for preventing UTI, related to the suprapubic catheter, was first initiated on 5/26/17, and should have been completed sooner, since the resident was admitted to the facility with a suprapubic catheter.
b. A review of Resident 3's Admission Record Face Sheet indicated the resident was a 52 year-old male who was originally admitted to the facility on XXXXXXX16. Resident 3?s diagnoses included paraplegia (paralysis affecting all or part of the trunk, legs, and pelvic organs), neuromuscular dysfunction of the bladder (inability to control the bladder due to a brain, spinal cord, or nerve condition), and urethral stricture (narrowing of the urethra).
A review of Resident 3's MDS, dated 4/24/17, indicated the resident reported the correct year, month, and day of the week, and did not have memory problems. The MDS indicated Resident 3 required extensive assistance (staff providing weight-bearing support), from one staff for toilet use and bed mobility. Resident 3?s MDS indicated the resident had an indwelling urinary catheter (a tube that drains urine from the bladder into a bag outside the body), and was always incontinent of bowel (inability to control). The MDS indicated Resident 3 had two Stage IV pressure ulcers with measurements of 1.3 centimeters (cm) in length, 1.5 cm in width, and 1.4 cm in depth.
A review of Resident 3's Care Plan titled, "Resident has Urinary Catheter Related to Neurogenic Bladder (abnormal bladder function resulting from damage to the nerves) , and hypospadias ( the opening of the penis is on the underside rather than the tip) with a History of Chronic UTI," initiated on 10/22/16, and revised on 5/26/17, indicated the staff?s interventions included to maintain free flow of the urine, monitor for signs and symptoms of UTI, and to position the drainage system (tubing and collection bag) to facilitate the flow of urine.
A review of Resident 3's May 2017 recapped Physician?s Order Summary Report, indicated an order dated 2/13/17, to monitor and document the resident's urine output for color and consistently every day.
A review of Resident 3's Change of Condition Record, dated 4/19/17, at 4 a.m., indicated the resident had a decrease in urinary output from the indwelling urinary catheter, and abdominal distention (enlarged and swollen from internal pressure). The record indicated Resident 3 was transferred to the GACH for evaluation.
A review of Resident 3's Physician?s Order, dated 5/10/17, at 1:46 p.m., indicated the resident was transferred to the GACH for low urine output and bladder distention.
A review of Resident 3's Change of Condition Record, dated 5/11/17, and timed at 12:59 a.m., indicated the resident was started on Levaquin (an antibiotic) 500 mg, for seven days to treat the UTI.
A review of Resident 3's Medication Administration Record (MAR), for the month of May 2017, indicated the resident received 500 mg, of Levaquin, daily for seven days (5/11/17 to 5/17/17), for the diagnosis of UTI.
A review of Resident 3's Change of Condition Record, dated 5/27/17, at 10 p.m., indicated the resident had abdominal distention with pain of seven out of 10 on a pain scale (10 being severe pain), and had new physician?s orders to be transferred to the GACH for evaluation.
A review of Resident 3's Physician?s Order, dated 5/28/17 and timed at 12:03 p.m., indicated to administer Cipro ([Ciprofloxacin] an antibiotic) 500 mg, one tablet orally, every 12 hours for 14 days, for the diagnosis of UTI.
On 5/26/17, at 12:20 p.m., during a wound care observation and a concurrent interview, Resident 3's urinary drainage bag was placed on top of the bed, above the resident's bladder. LVN 2 stated the urinary drainage bag should be placed below the resident's bladder.
According to an online article titled, ?Foley Catheter,? indicated the care of an indwelling urinary catheter included to ensure the tubing was not kinked or twisted, catheter not dragging the floor and to keep the bag below the level of the bladder to prevent backflow and UTIs. Http://www.emedicinehealth.com/foley_catheter/article_em.htm
On 6/21/17 at 1:30 p.m., during an interview, CNA 2 stated the urinary drainage bag of residents with indwelling urinary catheters, are kept low, not touching the floor, and not raised up.
On 6/21/17, at 2 p.m., during an interview, LVN 3 stated licensed nurses are responsible to ensure the urinary drainage bag of residents with indwelling urinary catheters are not raised above the bladder at any time.
A review of the facility's policy and procedure titled, "Catheter Care, Urinary," with a revision date of 10/2010, indicated to check the resident frequently to keep the catheter and tubing free of kinks, and to empty the urinary drainage bag regularly. The policy indicated to position the urinary drainage bag lower than the bladder at all times, and to keep the catheter tubing and urinary drainage bag off the floor. The policy indicated to check the resident's urine for unusual appearance, and to observe for other signs and symptoms of UTI or urinary retention (the inability to completely empty the bladder). The policy indicated accurately recording the characteristics of the resident's urine in the medical record.
The facility failed to provide each resident with the necessary care and services in accordance with the comprehensive assessment and plan of care to ensure residents, who had urinary catheters, received appropriate treatment and services to prevent urinary tract infections (UTI), including but not limited to:
1. Failure to accurately assess and monitor urine characteristics and report abnormalities to the physician as per the residents? plan of care and the facility?s policy.
2. Failure to implement the resident?s care plan in the prevention of UTIs.
3. Failure to ensure the resident?s urinary catheter tubing was not kinked and the urinary bag was not placed above the bladder as per the facility?s policy.
The above violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical or mental harm would result. |
| 960002063 |
UNITED CARE HOMES - KINBRAE |
960009026 |
B |
17-Feb-12 |
C89G11 |
4787 |
Class B Citation ? Administration Health and Safety Code Section 1265.5 (f)1265.5(f) Upon employment of any person specified in subdivision (a), and prior to any contact with clients or residents, the facility shall submit fingerprint cards to the Department for the purpose of obtaining a criminal record check.On January 14, 2011, an onsite investigation was conducted regarding Staff A?s denial for criminal clearance from the Department of Justice.Based on interview and record review, the facility failed to: 1. Ensure Staff A, who was hired on October 25, 2010, had criminal clearance prior to any contact with clients and did not continue to work after a denial of criminal clearance was issued.On January 14, 2011 at 11:50 a.m. during the entrance conference, the qualified mental retardation professional (QMRP) stated she did not receive notification from the Department of Justice, that Staff A was not criminally cleared. When the evaluator asked to review Staff A?s personnel file, she stated that she could not find the personnel file for Staff A and could not explain where the file was located. The QMRP further stated that ?This investigation? prompted her to terminate Staff A. On January 17, 2011, the evaluator received a fax copy of a memorandum from the QMRP indicating that Staff A?s file was located and it revealed Staff A was convicted of a misdemeanor over a year ago. According to the QMRP, Staff A?s date of hire was October 25, 2010, which was the date he was given orientation by the QMRP and was sent out to complete a live scan. Staff A started a work shift on October 30, 2010. A review of Staff A?s facility personnel status report, dated January 14, 2011, indicated he was discharged for cause due to denial of criminal record clearance and the falsification of the job application?s question regarding being convicted in the last 7 years which he answered ? No ?. A review of a fax transmittal copy dated September 20, 2011 from California Department of Public Health Licensing and Certification, Criminal Background Section in Sacramento, California revealed the denial letter for criminal background clearance for Staff A was sent certified mail and was delivered to the facility on November 3, 2010, November 8, 2010, and November 18, 2010, but was never claimed by the facility.There was no change in the mailing address which is also the facility?s home address of 1160 Kinbrae Avenue, Hacienda Heights, CA 91745. On February 1, 2012 at 9:20 a.m., during a telephone interview, the facility?s QMRP could not explain why the denial letter was not claimed.A review of the facility?s personnel policies under application indicated that an applicant?s electronic finger print images (Live Scan) must be completed as part of the application process prior to any contact with residents of the facility. The Live Scan, per Department of Justice will determine any convictions of a crime other than a minor traffic violation. The possibility of immediate dismissal included as follows: falsification of any records, insubordination, and disorderly conduct. There were six clients in the facility during the period of the violation.Client 1 was admitted to the facility on July 19, 1997 with diagnoses that included mild mental retardation and required assistance with safety awareness monitoring, bathing, dressing and hygiene.Client 2 was admitted to the facility on September 6, 2004 with diagnoses that included mild mental retardation and required assistance with safety awareness monitoring, eating, bathing, dressing and hygiene. Client 3 was admitted to the facility on March 5, 2010 with diagnoses that included mild mental retardation and required assistance with safety awareness monitoring, eating, bathing and dressing.Client 4 was admitted to the facility on February 13, 1999 with diagnoses that includedmild mental retardation; and required assistance with safety awareness monitoring, bathing, dressing and hygiene.Client 5 was admitted to the facility on August 19, 1998 with diagnoses that include profound mental retardation and totally dependent on staff for bathing, dressing and hygiene and safety awareness. Client 6 was admitted to the facility on September 3, 2010 with diagnoses that include mild mental retardation and required assistance with bathing, dressing and hygiene and safety awareness monitoring Failure of the facility to ensure that Staff A had a criminal record clearance prior to contact with clients and did not continue to work after a denial of criminal clearance was issued, placed all six clients at risk for potential harm/or abuse. The above violation had a direct relationship to the safety and security of the clients in the facility. |
| 960001997 |
UCP DRONFIELD NORTH |
960009734 |
B |
08-Feb-13 |
KTF311 |
6239 |
4502. Persons with developmental disabilities have the same legal rightsand responsibilities guaranteed all other individuals by United States 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, denied benefits of, or be subjected to discrimination under any program or activity, which receives public funds. It is the intent of the legislature that persons with developmental disabilities shall have rights, including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse or neglect. On August 16, 2012, at 6:00 a.m., an unannounced visit was made to the facility to conduct a complaint investigation. A reported incident was investigated involving Client 1 being fed mashed potatoes with cheese that was too hot, resulting insecond degree burns to his lower lip and roof of his mouth.Based on interview and record review, the facility failed to ensure Client 1 was free from harm by failing to check the temperature of the mashed potatoes that was heated in a microwave oven before spoon feeding Client 1. The Client sustained second degree burns on his lower lip and roof of his mouth. A review of Client 1?s health record indicated the client was admitted to the facility on February 5, 1996. His diagnoses included Cerebral Palsy (a condition caused by brain damage around the time of birth and marked by lack of muscle control, especially in the limbs), quadriplegic (the inability to move all four limbs or the entire body below the neck) moderate retardation (intellectual disability that interferes with someone?s intelligence and capacity for adaptive behavior at a moderate level), severe Scoliosis (an excessive sideways curvature of the human spine), dislocated right hip (refers to the ball of the femur slipping out of the hip socket), and aphasia (a condition characterized by either partial or total loss of the ability to communicate verbally or using written words). Client 1 is totally dependent upon direct care staff (DCS) for all activities of daily living. On August 16, 2012, at 10:00 a.m., a review of the facility?s special incident report (SIR) dated July 23, 2012; indicated Client 1 requested mashed potatoes with cheese for dinner. Direct Care Staff (DCS) A microwaved the food and spoon fed Client 1 a bite and he indicated it was too hot. DCS A stirred the food and let it sit for three to four minutes, then checked to see if temperature was lower by putting a small amount in her hand. The temperature felt cool enough and she fed the client the rest of the food with no complaints from the client. On the SIR form, under Section 2, what do you believe caused the incident? The written response indicated ?Temperature of food was not properly checked when it was taken from the microwave.? During an interview on August 17, 2012, at 9:30 a.m., DCS A stated, Client 1 wanted his mashed potatoes reheated in the microwave. She reheated the mashed potatoes in the microwave and spoon fed the potatoes to Client 1. She did not check the temperature of mashed potatoes before feeding him. Client 1 indicated the potatoes were too hot. She set the potatoes aside for about three to four minutes, and then fed the rest of the meal without any problems. On August 19, 2012, at 10:00 a.m., a review of the Interdisciplinary Notes, written by the registered nurse dated July 23, 2012 at 8:30 a.m., indicated on arrival to the facility, staff told her that Client 1 had burns on his lower lip and the roof of his mouth. Client 1 indicated it happened at dinner on July 22, 2012.Arrangements were made to send Client 1 to a medical center for assessment. Client 1 indicated he was having pain, but it wasn?t severe. His lower lip was swollen with two patches of burned area approximately one half inch each. The roof of his mouth had two by two burned areas. In an interview with the staff who fed Client 1 dinner, she stated Client 1 wanted his mashed potatoes with cheese reheated in the microwave.She reheated the mashed potatoes with cheese. She did not check the temperature of the potatoes before feeding him the first bite. When he indicated the potatoes were too hot, the direct care staff (Staff A) let them cool for a few minutes before feeding him the rest. No burns were seen on the evening shift.On August 19, 2012, at 11:00 a.m., a review of the form titled, Continuity of Care, filled out by the medical center dated July 23, 2012, indicated second degree burns to lower lip and mouth. The doctor ordered, Chlorhexidine 012 % (is used to treat gingivitis) solution apply with large Q-tip bid (twice a day) for one week and Lidocaine 2% jelly (is a sterile aqueous product that contains a local anesthetic agent and is administered topically) apply to lower lip and roof of mouth three times a day, for one week. The physician also ordered, clear to full liquids.During an interview on November 27, 2012, at 1:25 p.m., the registered nurse (RN) stated she came to the facility in the morning after Client 1 was burned on July 23, 2012. Staff informed her Client 1?s mouth was burned. The RN stated staff always reheats the client?s food in the microwave. The RN further stated at the time Client 1 was burned, the facility did not have a policy in place regarding heating clients? food in the microwave. Client 1 was sent to the medical center for treatment where his physician is located. The client came back with an order for topical Lidocaine three times a day for one week and Peridex swabs to the mouth. Client 1 was placed on clear liquids for one week and home for one week.The facility staff failed to check the temperature of the mashed potatoes before spoon feeding Client 1. This failure resulted in Client 1 sustaining second degree burns to the roof of his mouth and lower lip. The above violation had a direct and immediate relationship to the health, safety, or security of the patient. |
| 960000882 |
UCP/SCF ICF/DD-H HUBBARD |
960010474 |
A |
07-Mar-14 |
Y8RW11 |
5472 |
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.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 receives public funds. It is the intent of the Legislature that persons with developmental disabilities shall have rights including, but not limited to, the following: (h) A right to be free from harm, including unnecessary physical restraint, or isolation, excessive medication, abuse, or neglect.On January 15, 2014, an unannounced visit was made to the facility to conduct an annual survey. A reported incident which involved quality of care was investigated. Based interview and record review, the facility?s staff failed to ensure Client 3 was free from harm by failing to: 1. Follow the correct procedure using a Hoyer lift according to the facility?s policy and procedures. Client 3 was admitted to the facility on March 30, 2004, with diagnoses that included severe intellectual disability (cognitive ability that is markedly below average level- one fifth to one third of chronological age- and a decreased ability to adapt to one's environment) cerebral palsy (a group of disorders that effect a person's ability to move and maintain balance and posture related to the brains ability to control the body), and history of seizures (epilepsy, a brain disorder involving repeated, spontaneous convulsions). Client 3 was wheelchair dependent, nonverbal, and dependent on staff for all activities of daily living. The facility?s policy and procedure titled ?Basic Guidelines and Safety Procedures for Client Transfers? indicated 2 direct care staff should work together when using either a full or standing lift device.A review of an incident report dated November 29, 2013, indicated Client 3 was being transferred from the bed to her wheelchair and fell to the floor from a Hoyer mechanical lift. Client 3 was bleeding from the nose. A review of the facility?s investigation report completed by the Administrator dated November 28, 2013, indicated Staff D performed the transfer alone without help from other staff. On November 29, 2013, the report further indicated staff stated, ?I transferred by myself, I just don?t follow the rules.? The report also indicated staff stated, ?I am so sorry, I was wrong, the hook was not right.?During an interview with the Administrator, on January 16, 2014, at 4:00 p.m., she stated the staff was fired due to her incompetence. She stated, Staff D violated the use of the lift policy and the staff should have made sure she had a buddy to assist her with moving the clients. The Administrator further stated Staff D did not attach the lift as he was supposed to and as a result the client fell from the lift on her face to the floor requiring a visit to the emergency room and subsequent hospitalization. On January 15 to January 17, throughout the survey, Staff D was unavailable for interview. Client 3?s History and Physical, dated November 28, 2013, from an acute care hospital was reviewed. The report indicated Client 3 was brought to the emergency room after a fall during a transfer. The report further indicated Client 3 fell onto her face during a transfer. Client 3 was diagnosed with a fracture of the left nasal (pertaining to the nose) bone and of the right maxilla (pertaining to the upper jaw). Client 3?s Discharge Summary from the hospital dated December 2, 2013 indicated Client 3 had ecchymosis (bruising) under both eyes and will continue using a nasal splint (a device used to stabilize nose bones) for 10 to 14 days. Client 3?s Physical Therapy evaluation dated April 7, 2013, indicated, Client 3 used a manual wheelchair. The report also indicated Client 3 had no independent balance skills or protective reactions in any position. Client 3 had poor control overall with poor endurance and was dependent for transfers utilizing the Hoyer Lift (equipment used to transfer clients by lifting). A review of the facility?s Client Transfer Policy Acknowledgment, indicated no person will be allowed to perform a one person lift effective February 1, 2007, which was signed by Staff D on April 7, 2007, September 20, 2011, and July 26, 2013. The policy further indicated 2 direct care staff should work together when using the lift and slings must be attached to the hanger.A review of the facility?s ?Employee Separation Form?, dated December 16, 2013, indicated Staff D was terminated due to violation of company policy by not using a two person lift and causing injury to a client. The Facility staff failed to ensure Client 3 was free from harm by failing to: 1. Follow the correct procedure using a Hoyer lift according to the facility?s policy and procedures.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. |
| 960000869 |
UCP/SCF ICF/DD-N WENDT HOUSE |
960011773 |
B |
09-Oct-15 |
8BC611 |
2654 |
1265.5 (f) (f) Upon the employment of any person specified in subdivision (a), and prior to any contact with clients or residents, the facility shall ensure that electronic fingerprint images are submitted to the Department of Justice for the purpose of obtaining a criminal record check. On November 17, 2014, an unannounced visit was made to the facility to conduct an annual Fundamental Survey. The facility failed to ensure a criminal clearance for one direct care staff (DCS) A was submitted to the Department of Justice (DOJ) prior to providing care to 6 of 6 clients residing in the facility. This failure placed all 6 clients at risk for harm. The clinical record for Clients 1, 2, 3, 4, 5 and 6 were reviewed on November 19, 2014, indicating the clients had diagnoses that included a range of moderate, severe and profound intellectual disabilities and depended on staff for all activities of daily living. On November 19, 2014, a review of DCS A?s employee file indicated she was hired on September 18, 2014 for the position of DCS. There was no documentation to support a Live Scan and Transmittal application had been submitted to the DOJ for the purpose of obtaining a criminal record clearance. On November 19, 2014 at 12:57 p.m., the Interactive Voice Response Unit (IVRU) was called for verification of Live Scan Application submission. The IVRU recording indicated there was no record on file for Staff A. On November 19, 2014 at 1:08 p.m., during a telephone interview with the program technician II of the California Department of Public Health (CDPH) Live Scan Clearance division, he stated there was no record on file for criminal clearance therefore Staff A was not cleared to work in the facility. On November 19, 2014 at 1:10 p.m., during an interview with the Administrator (ADM), he stated when new employees are hired; the human resources department at corporate office handles the paperwork which includes the Live Scan procedure. On November 19, 2014 at 2:15 p.m., during an interview with the human resources manager of the corporate office, she stated the human resources department was responsible for sending new hires for Live Scan procedure to ensure they are cleared for criminal clearance to work in their Intermediate Care Facility. She further stated they accepted another agency's (day program) criminal background clearance and did not send DCS A for a Live Scan.Failure of the administrative staff to ensure DCS A had criminal clearance placed all 6 clients at risk for potential harm. The above violation had a direct relationship to the safety and security of the clients residing in the facility. |